Migraine relief: long-acting steroid does not beat dexamethasone

  • Latev A & al.
  • Ann Emerg Med
  • 15 Nov 2018

  • curated by Jenny Blair, MD
  • Clinical Essentials
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Takeaway

  • Patients with migraine treated with long-acting methylprednisolone acetate (e.g., Depo-Medrol; Pfizer) do not experience more headache-free days following discharge than those who receive dexamethasone.
  • These patients should receive anticipatory guidance.

Why this matters

  • Most patients treated in the emergency department (ED) for migraine redevelop headache within 48 hours of discharge.
  • Dexamethasone is efficacious when combined with migraine-abortive medication.
  • A depot steroid like methylprednisolone acetate, which remains active for 14 days, might theoretically offer longer-lasting relief.
  • This drug has not previously been investigated for migraine, to the authors’ knowledge.

Key results

  • Methylprednisolone vs dexamethasone: 
    • Headache days: 3.3 vs 3.0 (95% CI for difference, −0.4 to 1.1);
    • Freedom from headache for entire week: 5% (6/110) vs 9% (10/107) (95% CI for difference, −3% to 11%).

Study design

  • Randomized researcher-masked 2-ED clinical trial in the Bronx, NY.
  • 220 adults with moderate-severe migraine received 10 mg intravenous metoclopramide (e.g., Reglan) plus either 10 mg intramuscular dexamethasone or 160 mg intramuscular methylprednisolone.
  • Outcome: headache days in the week after ED discharge.
  • Funding: Montefiore Emergency Department; Harold and Muriel Block Institute for Clinical and Translational Research at Einstein and Montefiore.

Limitations

  • Impossible to mask patients to study-drug assignment.

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