Is dexamethasone used for migraine treatment?

Dexamethasone in Migraine Treatment

Dexamethasone is not recommended as a first-line or routine treatment for migraine, but it may have a specific role in preventing headache recurrence after standard treatment and in managing status migrainosus (migraine lasting >72 hours). 1, 2

Standard Migraine Treatment Approach

First-Line Treatment

• NSAIDs are recommended as first-line therapy for most patients with migraine headaches, including aspirin, ibuprofen, naproxen sodium, and diclofenac potassium 1, 3
• Combination therapy of acetaminophen plus aspirin plus caffeine is effective, though acetaminophen alone is not recommended 3
• Treatment should begin as early as possible during an attack for maximum efficacy 3

Second-Line Treatment

• Triptans are recommended as second-line therapy for patients who do not respond adequately to NSAIDs 3, 4
• For patients with severe nausea or vomiting, non-oral triptans or adding an antiemetic such as metoclopramide or prochlorperazine is recommended 3, 4

Third-Line Treatment

• CGRP antagonists-gepants, ditans, or dihydroergotamine are options for patients who fail all available triptans or have contraindications 3

Role of Dexamethasone in Migraine Treatment

Preventing Headache Recurrence

• Dexamethasone may be useful as an adjunctive therapy to prevent headache recurrence after standard migraine treatment 2
• A systematic review found a median absolute risk reduction of 30% for 24-hour headache recurrence and 11% for 72-hour recurrence when dexamethasone was added to standard treatments 2
• Parenteral dexamethasone (typically 10 mg IV) has shown efficacy in reducing migraine recurrence when added to other abortive medications 2

Status Migrainosus

• For status migrainosus (migraine lasting >72 hours), dexamethasone (4 mg orally twice daily for 3 days) showed a 31% success rate in rendering patients pain-free within 24 hours 5
• In patients with migraine lasting longer than 72 hours, 38% of those receiving dexamethasone were persistently pain-free compared to 13% with placebo (p=0.06) 6

Combination Therapy

• Adding dexamethasone (4 mg) to a triptan plus NSAID combination significantly reduced recurrence rates from 60% to 23.4% in patients who previously experienced frequent recurrence 7

Important Considerations and Cautions

• Routine use of dexamethasone for acute migraine is not supported by guidelines 1, 3, 4
• Medications to avoid in migraine treatment include oral ergot alkaloids, opioids, and barbiturates due to questionable efficacy, adverse effects, and risk of dependency 1
• Medication overuse headache is a risk when acute treatments are used too frequently (≥15 days per month with NSAIDs or ≥10 days per month with triptans) 3
• Side effects of dexamethasone are generally tolerable in short-term use for migraine 2, 8
• Factors that may predict favorable response to dexamethasone include higher disability, status migrainosus, incomplete pain relief with standard treatments, and previous history of headache recurrence 2

Algorithm for Dexamethasone Use in Migraine

1. Start with standard first-line (NSAIDs) or second-line (triptans) migraine treatments 1, 3
2. Consider adding dexamethasone (typically 4-10 mg) in the following scenarios:
   • Status migrainosus (migraine lasting >72 hours) 5, 6
   • History of frequent headache recurrence after standard treatment 7, 2
   • Incomplete pain relief with standard treatments 2
3. Monitor for response and limit use to avoid medication overuse headache 3