What is the role of steroids in treating chronic primary headaches?

Role of Steroids in Chronic Primary Headaches

Steroids are primarily indicated for status migrainosus (a severe, continuous migraine lasting up to one week) and medication overuse headache, but have limited evidence supporting their use in routine management of chronic primary headaches. 1, 2

Appropriate Uses for Steroids in Headache Management

• Steroids may be the treatment of choice for patients with status migrainosus, though there are no good studies documenting their efficacy in treating acute migraine attacks 1
• Short courses of rapidly tapering doses of oral corticosteroids (prednisone or dexamethasone) can be effective for alleviating status migrainosus 3
• Intravenous corticosteroids (methylprednisolone) as single or multiple doses can be used to break long-lasting migraine attacks 3
• Corticosteroids have shown benefit in managing medication overuse headache ("rebound headache") during the detoxification process 3, 4

Evidence for Specific Headache Types

• For chronic migraine: Steroids are not listed among the recommended prophylactic medications in current guidelines 1
• For cluster headache: Greater occipital nerve injections with long-acting steroids (three injections of 60 mg methylprednisolone on alternate days) have shown effectiveness in both episodic and chronic cluster headache 5
• For medication overuse headache: Corticosteroids can help manage withdrawal symptoms when discontinuing overused medications 3, 4

Limitations and Precautions

• Steroids should not be used as regular abortive drugs for episodic migraine attacks 3
• They are never recommended as standard migraine preventives due to risk of side effects with prolonged usage 3
• Corticosteroids can be administered safely up to six times annually, but should not be used chronically 4
• First-line treatments for chronic primary headaches should include:
  • For prophylaxis: Topiramate, valproate, beta-blockers, and onabotulinumtoxinA (for chronic migraine) 1
  • For acute treatment: NSAIDs, triptans, and combination analgesics 1, 6

Patient Selection for Steroid Therapy

• Best candidates for steroid therapy include:
  • Patients with refractory headaches not responding to standard treatments 4
  • Those with history of recurrent headaches 4
  • Patients with severe baseline disability 4
  • Those experiencing status migrainosus 1, 4

Administration Methods

• For status migrainosus:
  • Oral: Short courses of rapidly tapering doses of prednisone or dexamethasone 3
  • Intravenous: Single dose in emergency setting or several days of repetitive dosing for inpatient treatment 3
• For cluster headache:
  • Greater occipital nerve injections with methylprednisolone 5
• For medication overuse headache:
  • Short courses of oral corticosteroids or repetitive intravenous therapy 3

Monitoring and Follow-up

• Monitor for adverse effects including edema, mood changes, insomnia, and elevated blood glucose 3
• Limit steroid use to avoid long-term complications such as osteoporosis, adrenal suppression, and increased infection risk 3
• Document response to treatment to determine effectiveness for future episodes 4