Can steroids help with migraines?

Steroids for Migraine Treatment

Steroids are not effective for routine acute migraine treatment but may be beneficial in specific situations such as status migrainosus or preventing headache recurrence after emergency treatment.

Efficacy of Steroids in Migraine Management

Routine Acute Migraine Treatment

• According to the American College of Physicians, steroids are not recommended as first-line treatment for acute migraine attacks 1
• The Annals of Internal Medicine explicitly states that "intravenous corticosteroids and intranasal lidocaine are not effective" for acute migraine treatment 2
• First-line treatments for acute migraine should instead include:
  • NSAIDs such as ibuprofen (400-600mg) or naproxen sodium (500-550mg) 1
  • Triptans such as sumatriptan (50mg orally or 6mg subcutaneously) 1
  • Acetaminophen (1000mg) for milder cases 1

Specific Situations Where Steroids May Help

1. Status Migrainosus (migraine lasting >72 hours)

   • Parenteral corticosteroids are recommended for treatment of status migrainosus in emergency settings 3
   • Both oral and intravenous corticosteroids in either single-dose or short-tapering schedules have shown efficacy 4

2. Prevention of Headache Recurrence

   • Steroids can provide protection against headache recurrence after emergency treatment 5
   • Dexamethasone has been shown to reduce migraine recurrence when added to triptan plus NSAID combinations in patients with frequent recurrences 6

3. Medication-Overuse Headache

   • Corticosteroids can be useful during the detoxification process for patients with medication-overuse headache 7
   • Both outpatient (oral) and inpatient (intravenous) corticosteroid regimens have been used 7

Important Considerations and Limitations

• Corticosteroids should be administered safely no more than six times annually to avoid adverse effects 4
• Patients with refractory headaches, history of recurrent headaches, severe baseline disability, and status migrainosus benefit most from corticosteroid therapy 4
• For routine migraine management, evidence-based options should be prioritized:
  • NSAIDs and triptans for acute treatment 1
  • Beta-blockers, tricyclic antidepressants, or CGRP antagonists for prevention 1

Practical Approach to Migraine Management

1. For typical migraine attacks:

   • Start with NSAIDs or triptans as first-line treatment 1
   • Avoid steroids for routine management 2

2. For prolonged or refractory migraine:

   • Consider dexamethasone (typically 4mg) when other treatments have failed 6
   • Particularly useful in emergency settings or for preventing recurrence 5

3. For medication-overuse headache:

   • Short course of corticosteroids may help manage withdrawal symptoms during detoxification 7

Common Pitfalls to Avoid

• Using steroids as routine first-line treatment for migraine attacks
• Administering steroids more than six times per year
• Relying on steroids without addressing underlying causes of frequent or severe migraines
• Failing to consider preventive therapy for patients with frequent migraines

Remember that while steroids have a role in specific migraine scenarios, they should not replace evidence-based first-line treatments for routine migraine management.