Does Addition of Dex in ED Treatment Reduce Migraine Recurrence?

Background

  • Migraines affect 1/5 adults in US[1]
  • 5th most common ED visit1
  • Affects 18% of women and 6% of men in US[2]
  • Associated with $17 billion/yr health care related cost[3]
  • 5-11% of pts return to the ED with symptoms[4]

EBM

  • Symptom recurrence can be reduced by using a combination of standard abortives and dexamethasone.[5]
  • A 2013 meta-analysis in which eight studies with a combined 905 patients showed that addition of steroids to a standard abortive can reduce the rate of recurrence with a RR of .71 (95%CI 0.59-0.86). The authors also noted that there was no benefit in administration of steroids after migraine resolution.[6]
  • A 2011 RCT placebo study looked at the efficacy of steroids in preventing migraine recurrence and found that steroids did not prevent the recurrence of migraines.[7]
  • A 2007 study examined the efficacy of 10mg IV dexamethasone in ED migraine management. Patients were randomized to dexamethasone or placebo. 25% of patients who received dexamethasone and 19% of placebo patients were pain-free (p=.34). In patients with migraines lasting longer than 72 hours 38% of dexamethasone patients and 13% of placebo patients were pain free (p=.06). The study’s authors concluded that dexamethasone should not be used unless the migraine has lasted greater than 72 hours. [8]
  • A systematic review from 2008 showed a benefit when using dexamethasone to reduce the rate of migraine recurrence at 24 and 72 hour follow-up (RR=.87, ARR 9.7%). The study concluded that the minor and infrequent adverse reactions coupled with demonstrated benefit make dexamethasone a viable ED option to prevent recurrence[9].

Consensus

Based on the current available data and relative low risk of dexamethasone it is not unreasonable to add this therapy to ED migraine management.

References

  1. Smitherman TA, Burch R, Sheikh H, et al. The prevalence, impact, and treatment of migraine and severe headaches in the United States: a review of statistics from national surveillance studies. Headache 2013; 53: 427-436.
  2. Gupta MX, Silberstein SD, Young WB, Hopkins M, Lopez BL, Samsa GP. Less is not more: underutilization of headache medications in a university hospital emergency department. Headache. 2007; 47:1125-1133.
  3. Goldberg L: The cost of migraine and its treatment. Am J of Manag Care 2005; 11: S62-S67.
  4. Colman I., Rothney A., Wright S.C. et al. Use of narcotic analgesia in the emergency department treatment of migraine headaches. Neurology 2004; 62: 1695-1700.
  5. Saguil A & JW Lax. Acute Migraine Treatment in Emergency Settings. Am Fam Phys. 2014; 8(9): 742-744.
  6. Huang Y, Cai X, Song X, Tang H, Huang Y, Xie S & Y Hu. Steroids for preventing recurrence of acute severe migraine headaches: a meta-analysis. European Journal of Neurology. 2013; 20:1184-1190.
  7. Fiesseler FW, Shih R, Szucs P, Silverman ME, Eskin B, Clement M, Saxena R, Allergra J, Riggs RL, & N Majiesi. Steroids for migraine headaches: a randomized double-blind two armed placebo controlled trial article summary.  J Emerg Med. 2011; 40(4):463-468.
  8. Randomized trial of IV dexamethasone for acute migraine in the emergency department. Friedman BW, Greenwald P, Bania TC, Esses D, Hochberg M, Solorzano C, Corbo J, Chu J, Chew E, Cheung P, Fearon S, Paternoster J, Baccellieri A, Clark S, Bijur PE, Lipton RB, Gallagher EJ – Neurology – Nov 2007; 69(22); 2038-44.
  9. Does the addition of dexamethasone to standard therapy for acute migraine headache decrease the incidence of recurrent headache for patients treated in the emergency department? A meta-analysis and systematic review of the literature. Singh A, Alter HJ, Zaia B – Acad Emerg Med – Dec 2008; 15(12); 1223-33.

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