What is the role of prednisone in treating severe headache not relieved by Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) or triptans?

Prednisone for Severe Headache Not Relieved by NSAIDs or Triptans

Systemic steroid therapy such as prednisone may be considered as a treatment option for status migrainosus (severe, continuous migraine lasting up to one week) when first and second-line treatments have failed, but is not recommended as a routine treatment for typical migraine attacks. 1

Treatment Algorithm for Severe Headache

First-Line Treatments

• NSAIDs (aspirin, ibuprofen, naproxen sodium, diclofenac potassium) are the first-line treatment for mild to moderate migraine attacks 2
• Triptans (sumatriptan, rizatriptan, zolmitriptan, etc.) are recommended as second-line therapy when NSAIDs are ineffective 2
• Combination therapy of a triptan with an NSAID or acetaminophen is recommended for patients who do not achieve sufficient pain relief with either medication alone 2

Second-Line Treatments

• CGRP antagonists (gepants) such as rimegepant, ubrogepant, or zavegepant should be considered for patients who don't respond to or cannot tolerate NSAIDs and triptans 2, 1
• Dihydroergotamine (DHE), particularly in intranasal formulation, has good evidence for efficacy and safety 2, 1
• Lasmiditan (ditan) may be considered for moderate to severe acute episodic migraine when other options are contraindicated or ineffective 2, 1

When to Consider Prednisone

• Prednisone is not mentioned in the primary treatment algorithms for typical migraine attacks in any of the recent guidelines 2
• Systemic steroids may be appropriate for status migrainosus - severe, continuous migraine lasting up to one week that has not responded to standard treatments 1
• Steroids are not included in the standard stepped care approach for acute migraine treatment 2

Important Considerations

Medication Overuse Risk

• Limit use of acute treatments to no more than twice a week to prevent medication-overuse headaches 2
• Monitor for medication overuse headache, which can occur with frequent use of acute medications (≥15 days per month with most medications; ≥10 days per month with triptans) 2, 1
• Adding additional acute medications to triptan therapy has not been consistently associated with reductions in headache-related disability, particularly in high-frequency migraine 3

Treatment Failures

• For patients with frequent headaches (>10 days per month), limit acute treatments to only the most disabling episodes to avoid medication overuse 4
• If first and second-line treatments fail, consider preventive therapy to reduce frequency and severity of attacks 2
• Non-oral routes of administration should be selected when nausea or vomiting are significant components of migraine attacks 2

Treatments to Avoid

• Opioids and butalbital-containing medications should not be used for routine migraine treatment as they can lead to dependency, rebound headaches, and eventual loss of efficacy 2, 1, 4

Conclusion

While prednisone is not included in standard treatment algorithms for typical migraine attacks, it may have a role in treating status migrainosus when standard treatments have failed. The evidence-based approach focuses on NSAIDs, triptans, and their combinations as first-line treatments, followed by newer agents like gepants and ditans before considering steroids.