Steroid Injections for Acute Migraine Treatment
Steroid injections are NOT recommended as first-line or routine treatment for acute migraine attacks, but they have a specific role in preventing headache recurrence after emergency treatment and in managing status migrainosus (prolonged migraine lasting days to a week). 1
Primary Role of Steroids in Migraine Management
- Steroids serve two specific purposes in migraine care: reducing headache recurrence after emergency department discharge and treating status migrainosus, NOT as routine acute treatment. 1, 2
- There are no good studies documenting steroid efficacy in routine acute migraine attacks. 1
- Corticosteroids can reduce the rate of headache recurrence within 24-72 hours after discharge from emergency settings, where recurrence rates can exceed 50%. 3
First-Line Treatments You Should Use Instead
- For mild to moderate migraine: Start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) as first-line therapy. 4, 1
- For moderate to severe migraine: Use triptans (sumatriptan, rizatriptan, zolmitriptan) as first-line therapy, ideally combined with an NSAID for superior efficacy. 4, 1
- For emergency/urgent care settings requiring IV treatment: Use metoclopramide 10 mg IV plus ketorolac 30 mg IV as the optimal first-line combination. 4
When Steroids ARE Appropriate
- Status migrainosus (migraine lasting >72 hours): Use short courses of rapidly tapering oral corticosteroids (prednisone or dexamethasone) or single-dose IV methylprednisolone. 1, 2
- Prevention of headache recurrence: Add a single dose of corticosteroid (typically dexamethasone 10-20 mg IV or oral prednisone taper) when discharging patients from emergency settings after acute treatment. 3
- Drug-overuse headache detoxification: Corticosteroids can be used during the withdrawal process when discontinuing overused acute medications. 2
Critical Limitation to Prevent Medication-Overuse Headache
- Limit ALL acute migraine medications (including any steroids if used) to no more than 2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 4
- If you need acute treatment more than twice weekly, initiate preventive therapy immediately rather than increasing frequency of acute medications. 4
The Evidence Gap
- The American Academy of Family Physicians explicitly states that steroids lack robust evidence for routine acute migraine treatment, distinguishing them from NSAIDs and triptans which have strong efficacy data. 1
- The primary evidence supporting steroids comes from their role in reducing recurrence rates post-discharge, not in treating the acute attack itself. 3