What steroid regimen can be used for severe refractory migraine?

Steroid Regimen for Severe Refractory Migraine

For severe refractory migraine, dexamethasone can be administered at 10 mg IV initially, followed by 4 mg every 6 hours intramuscularly until symptoms subside, typically for 2-4 days, with gradual tapering over 5-7 days. 1

Indications for Steroid Use in Migraine

Corticosteroids are particularly beneficial for specific migraine presentations:

• Status migrainosus (prolonged migraine attacks)
• Patients with history of recurrent headaches
• Severe baseline disability
• Refractory headaches not responding to first-line treatments 2

Recommended Steroid Regimens

Intravenous Administration (Emergency Setting)

• Initial dose: 10 mg IV dexamethasone
• Maintenance: 4 mg every 6 hours IM until symptoms subside 1
• Duration: Response typically noted within 12-24 hours
• Tapering: After 2-4 days, gradually reduce dose over 5-7 days

Oral Administration (Outpatient Setting)

• Short tapering schedule of oral corticosteroids (prednisone or dexamethasone) 3
• Dexamethasone tablets: Start with higher dose and taper over 5-7 days

First-Line Treatments Before Considering Steroids

Before initiating steroid therapy, consider these first-line treatments:

• For mild to moderate migraines: Acetaminophen, NSAIDs 4, 5
• For moderate to severe migraines: Triptans (sumatriptan, rizatriptan, eletriptan, zolmitriptan, almotriptan, frovatriptan, naratriptan) 6, 4
• Antiemetics can be added as necessary 5

Treatment Algorithm for Refractory Migraine

1. First-line treatments:

   • NSAIDs (ibuprofen 400-800mg, naproxen sodium) 6
   • Triptans for moderate-severe attacks 6, 4

2. Second-line treatments:

   • Combination of triptans and NSAIDs simultaneously 5
   • Antiemetics (metoclopramide, prochlorperazine) 5, 7

3. Steroid rescue therapy (when above treatments fail):

   • Implement dexamethasone regimen as described above 1, 2
   • Consider as part of a comprehensive treatment plan for status migrainosus 3

Safety Considerations

• Corticosteroids can be administered safely up to six times annually 2
• Monitor for adverse effects including:
  • Peptic ulceration (especially with high-dose, short-term therapy) 1
  • Hyperglycemia
  • Mood changes
  • Sleep disturbances

Post-Discharge Considerations

• Steroids provide protection against headache recurrence after treatment 7
• Consider preventive treatments to reduce frequency of future attacks:
  • Beta-blockers (propranolol 80-240 mg/day, timolol 20-30 mg/day) 6
  • Anticonvulsants (topiramate 100 mg/day, divalproex sodium 500-1500 mg/day) 6
  • Tricyclic antidepressants (amitriptyline 30-150 mg/day) 6

Important Caveats

• Steroids should not be used as regular abortive therapy for episodic migraine attacks 3
• They are not indicated as migraine preventives due to risk of side effects with prolonged use 3
• Document response to steroid therapy to guide future treatment decisions
• Consider referral to a headache specialist if patient requires frequent steroid rescue therapy 6