What is the recommended dose of prednisone (corticosteroid) for treating migraines?

Steroid Dose in Migraines

Corticosteroids are not recommended as first-line or second-line therapy for acute migraine attacks, but when used for status migrainosus or medication overuse headache, prednisone 60 mg daily (or equivalent) for 5-6 days is the evidence-based dose. 1, 2

Evidence Against Routine Use

The available guideline evidence explicitly states that intravenous corticosteroids are not effective for routine acute migraine treatment 1. Multiple guidelines from the Annals of Internal Medicine and American Family Physician do not include corticosteroids in their recommended treatment algorithms for acute migraine attacks 1.

When Corticosteroids May Be Appropriate

Status Migrainosus

• Steroid therapy may be the treatment of choice for patients with status migrainosus (a severe, continuous migraine lasting up to one week), though good studies documenting efficacy are lacking 1
• This represents a specific clinical scenario distinct from typical acute migraine attacks 1

Medication Overuse Headache Detoxification

• Prednisone at least 60 mg daily is possibly effective for treating withdrawal symptoms during medication overuse headache detoxification 2
• A specific outpatient protocol uses prednisone in tapering doses over 6 days when abruptly stopping overused symptomatic medications 3
• In one study, 85% of patients experienced reduced headache frequency with no severe attacks during the first 6 days of this prednisone-based withdrawal protocol 3

Rescue Medication for Refractory Cases

• Corticosteroids may serve as rescue medications when other evidence-based treatments have failed 4
• This is reserved for patients who do not respond to NSAIDs, triptans, or combination therapy 4

Specific Dosing Regimens

When corticosteroids are indicated:

• Oral prednisone: 60 mg daily minimum for withdrawal symptom management 2
• Prednisolone: at least 60 mg daily as an alternative to prednisone 2
• Duration: 5-6 days with tapering schedule for outpatient detoxification 3
• Frequency limit: up to 6 times annually to maintain safety 5

Critical Clinical Algorithm

Step 1: Rule out status migrainosus or medication overuse headache before considering corticosteroids 1, 2

Step 2: If typical acute migraine, use evidence-based first-line therapy (NSAIDs or triptans) instead 1

Step 3: If status migrainosus is confirmed, corticosteroids become a reasonable option 1

Step 4: If medication overuse headache requires detoxification, initiate prednisone 60 mg daily with tapering over 6 days 3, 2

Important Caveats

• Most clinical studies (86%) showing corticosteroid efficacy used heterogeneous designs, making definitive recommendations difficult 5
• The evidence base consists primarily of older studies with methodological limitations 1, 5
• Corticosteroids should never be used as regular abortive drugs for episodic migraine attacks due to side effect risks with prolonged usage 6
• Patients most likely to benefit include those with refractory headaches, history of recurrent headaches, severe baseline disability, and status migrainosus 5