Can corticosteroids (steroids) cause anxiety and headaches as side effects?

Can Steroids Cause Anxiety and Headaches?

Yes, corticosteroids commonly cause both anxiety and headaches as documented side effects, with neuropsychiatric symptoms occurring in over 30% of patients and headaches listed as a recognized adverse effect in FDA labeling. 1

Anxiety and Neuropsychiatric Effects

Incidence and Presentation

• Psychiatric disturbances occur in approximately 28% of patients on corticosteroids for mild to moderate reactions, with severe reactions in nearly 6% of patients. 2
• Anxiety symptoms are well-documented and can range from mild nervousness and restlessness to severe anxiety requiring intervention. 1
• The FDA label for prednisone explicitly lists "insomnia, mood swings, personality changes, and severe depression, to frank psychotic manifestations" as neuropsychiatric adverse effects. 1

Timing and Dose Relationship

• Psychiatric symptoms typically present early in the treatment cycle, often within the first few days to weeks of therapy. 2
• Higher doses are directly associated with increased incidence of neuropsychiatric effects, though dosage does not predict the severity or duration of symptoms. 2
• Even short courses of steroids (<21 days) can trigger anxiety and sleep disturbances. 3

Specific Anxiety Manifestations

• Children on high-dose prednisone (mean 61.4 mg) demonstrated significantly more anxiety and depression symptoms compared to low-dose days (mean 6.97 mg). 4
• Sleep disturbances occur in more than 30% of patients taking corticosteroids, which can exacerbate anxiety symptoms. 5, 3
• Emotional instability, restlessness, and nervousness are common neuropsychiatric effects listed in FDA labeling. 1

Headaches as a Side Effect

Documentation in FDA Labeling

• Headache is explicitly listed as an adverse reaction in the FDA-approved prednisone labeling under neuropsychiatric effects. 1
• The mechanism may relate to increased intracranial pressure, which can occur with corticosteroid use, particularly when discontinuing treatment (pseudotumor cerebri). 1

Clinical Context

• While steroids are sometimes used therapeutically for certain headache types (status migrainosus, medication overuse headache), they can paradoxically cause headaches as a side effect. 6
• Headaches may occur during active treatment or as part of withdrawal syndrome when tapering or discontinuing steroids. 1

Risk Factors for Neuropsychiatric Effects

Patient-Specific Factors

• Pre-existing emotional difficulties or dysfunctional family environments increase the likelihood of negative psychological changes with high-dose steroids. 4
• Existing emotional instability or psychotic tendencies may be aggravated by corticosteroids. 1
• Neither previous reactions nor their absence predicts adverse responses to subsequent steroid courses. 2

Dose and Duration Considerations

• Dosage is directly related to incidence of adverse effects, with higher doses carrying greater risk. 2
• Long-term therapy (>3 months) tends to induce more depressive symptoms, while short-term therapy more commonly causes euphoria, hypomania, and anxiety. 2
• Duration of treatment longer than 6 weeks significantly increases risk of adverse effects. 5

Management Strategies

Prevention and Monitoring

• Use the lowest effective dose for the shortest duration possible to minimize neuropsychiatric side effects. 5, 3
• Inform patients proactively about the potential for anxiety, sleep disturbances, and headaches as common side effects. 3
• Monitor patients regularly for signs of psychiatric symptoms, particularly in the first few weeks of therapy. 2

Treatment of Steroid-Induced Anxiety

• Corticosteroid-induced psychiatric symptoms typically resolve with dosage reduction or discontinuation of steroids. 2
• In severe cases where dose reduction is not possible, antipsychotics or mood stabilizers may be required. 2
• Implement good sleep hygiene practices, as sleep disturbances can worsen anxiety symptoms. 3
• Consider referral to psychiatry or sleep specialist if symptoms are severe or persistent. 3

Tapering Considerations

• A taper schedule is required when discontinuing steroids to avoid withdrawal syndrome, which can include headaches, anxiety, myalgia, and malaise. 7, 1
• Patients should not discontinue corticosteroids abruptly or without medical supervision due to risk of adrenal insufficiency. 1

Important Clinical Pitfalls

Common Mistakes to Avoid

• Do not dismiss anxiety or mood changes as unrelated to steroid therapy—these are among the most common adverse effects. 5, 2
• Do not assume that absence of previous psychiatric reactions means a patient won't develop them with subsequent courses. 2
• Do not underestimate the impact of sleep disturbances on quality of life and treatment adherence. 5

Special Populations

• Children are particularly vulnerable to psychiatric effects and require close monitoring, especially those from emotionally difficult or dysfunctional family environments. 4
• Elderly patients require more careful monitoring and often lower doses due to increased risk of complications. 5

When to Seek Additional Help

• Consider psychiatric consultation for severe anxiety, mood changes, or psychotic symptoms that don't resolve with dose reduction. 2
• Evaluate for other causes of headaches if they are severe, persistent, or associated with visual changes (to rule out increased intracranial pressure). 1