From the Guidelines
Dexamethasone is not recommended as a first-line treatment for acute migraines, and its use should be considered on a case-by-case basis. The most recent and highest quality study, published in 2025 in the Annals of Internal Medicine 1, provides guidance on the pharmacologic treatments of acute episodic migraine headache in outpatient settings. According to this study, the choice of treatment should be based on individualized decision making, taking into consideration patient preferences and factors such as route of administration and cost.
Treatment Options
- For mild episodic migraine headache, consider treating with an NSAID, acetaminophen, or the combination of an NSAID and acetaminophen.
- For moderate to severe acute episodic migraine headache, consider using CGRP antagonists-gepants (rimegepant, ubrogepant, or zavegepant) or ergot alkaloid (dihydroergotamine) in nonpregnant outpatient adults who do not tolerate or have inadequate response to combination therapy of a triptan and an NSAID or acetaminophen.
Dexamethasone Consideration
While dexamethasone may be considered as an adjunctive therapy to prevent migraine recurrence, its use should be selective and based on individual patient needs, as it does not significantly improve immediate pain relief compared to standard treatments alone 1. The potential risks associated with corticosteroids, such as elevated blood sugar, mood changes, and increased infection risk, should also be taken into account.
Key Takeaways
- First-line treatments like triptans, NSAIDs, or antiemetics remain more effective for immediate migraine relief.
- Dexamethasone is best viewed as an adjunctive therapy to prevent the "rebound" headache that sometimes follows initial treatment success, and its use should be considered on a case-by-case basis.
From the Research
Dexamethasone in Acute Migraines
- The use of dexamethasone in acute migraines has been studied in several trials, with mixed results 2, 3.
- A randomized, double-blind, placebo-controlled multicenter trial found that 10 mg of IV dexamethasone as adjuvant therapy for patients presenting to an emergency department with acute migraine did not significantly improve outcomes compared to placebo 2.
- However, in the subgroup of subjects with migraine lasting longer than 72 hours, 38% of those randomized to dexamethasone were persistently pain-free vs 13% of placebo (p = 0.06) 2.
- Another study found that a single dose of dexamethasone as adjunctive therapy for migraine headache does not decrease the recurrence of migraines at 3 or 30 days 3.
Comparison to Other Treatments
- Triptans are considered effective for the acute treatment of migraine, with extensive evidence supporting their use 4, 5, 6.
- Non-steroid anti-inflammation drugs (NSAIDs) such as aspirin, diclofenac, ibuprofen, and naproxen are also considered effective for acute migraine treatment 5, 6.
- The American Headache Society recommends triptans, acetaminophen, and NSAIDs as first-line treatments for acute migraine 5.
Guidelines and Recommendations
- The Taiwan Headache Society recommends a "stratified care" approach, with oral NSAIDs as the first choice for mild to moderate migraine attacks, and triptans or ergotamine/caffeine compounds for moderate to severe attacks 5.
- Parenteral steroid and fluid supply are recommended for the treatment of status migrainosus 5.
- Dexamethasone is not recommended as a routine treatment for acute migraine, but may be considered for patients with migraine lasting longer than 72 hours 2.