What is the recommended dose of prednisone (corticosteroid) for migraine treatment?

Prednisone Dosing for Migraine Treatment

Prednisone is NOT recommended for routine acute migraine treatment, but when used for status migrainosus or medication-overuse headache detoxification, the evidence supports a short tapering course starting at 60-100 mg daily. 1, 2

When Prednisone Should NOT Be Used

• Intravenous corticosteroids are explicitly not effective for routine acute migraine attacks and are absent from all recommended treatment algorithms for typical migraine. 1
• First-line therapy for acute migraine should be NSAIDs (naproxen 500-825 mg, ibuprofen 400-800 mg) or triptans, not corticosteroids. 3
• The combination of triptan plus NSAID represents the strongest evidence-based approach for moderate-to-severe migraine, with 130 more patients per 1000 achieving sustained pain relief compared to monotherapy. 3

Specific Clinical Scenarios Where Prednisone May Be Appropriate

Status Migrainosus (Migraine Lasting >72 Hours)

• Prednisone may be the treatment of choice for status migrainosus, though high-quality studies documenting efficacy are lacking. 1
• The European Federation of Neurological Societies supports corticosteroids for status migrainosus, although this recommendation is not universally accepted. 4
• Dosing regimen: Short courses of rapidly tapering oral prednisone starting at 60-100 mg daily can alleviate status migraine. 5

Medication-Overuse Headache Detoxification

• For patients withdrawing from overused symptomatic medications, prednisone 60 mg daily tapered over 6 days is effective in an outpatient setting. 6
• Specific tapering schedule from the evidence: Start prednisone at 60 mg and taper over 6 days while simultaneously initiating preventive therapy. 6
• This approach resulted in 85% of patients experiencing reduced headache frequency during withdrawal, with no patients experiencing severe attacks during the first 6 days. 6

Prevention of Headache Recurrence After ED Treatment

• Single-dose IV dexamethasone 10 mg (not prednisone) reduces 24-hour headache recurrence by 30% when added to standard abortive therapy in the emergency department. 2
• This represents a reasonable option for resistant, severe, or prolonged migraine attacks in the ED setting specifically. 2
• Parenteral dexamethasone was the most commonly administered steroid in systematic review (56% of studies), at a median single dose of 10 mg (range 4-24 mg). 2

Critical Algorithm for Decision-Making

Before considering any corticosteroid:

1. Rule out medication-overuse headache (using acute medications >2 days per week). 3, 1
2. Determine if this is status migrainosus (continuous migraine >72 hours) versus typical acute attack. 1
3. For typical acute migraine: Use NSAIDs or triptans, NOT corticosteroids. 3, 1
4. For status migrainosus: Consider prednisone 60-100 mg daily with rapid taper over 5-6 days. 5, 2
5. For medication-overuse headache: Use prednisone 60 mg tapered over 6 days during detoxification. 6

Important Caveats and Pitfalls

• Higher disability, status migrainosus, incomplete pain relief, and previous history of headache recurrence predict better outcomes with corticosteroids, not routine migraine attacks. 2
• Adverse effects with short-course corticosteroids are generally tolerable, most commonly including palpitations, dizziness, and nausea. 7
• Never use corticosteroids as regular abortive drugs for episodic migraine attacks due to the risk of side effects with prolonged usage. 5
• The evidence for prednisone in migraine is substantially weaker than for cluster headache, where 100 mg daily for 5 days followed by tapering of 20 mg every 3 days showed clear efficacy. 7

What to Do Instead for Routine Migraine

• Limit all acute migraine medications to no more than 2 days per week to prevent medication-overuse headache. 3
• If requiring acute treatment more than twice weekly, initiate preventive therapy immediately with propranolol 80-240 mg/day, topiramate, or candesartan. 8
• For severe attacks in the ED: Use IV metoclopramide 10 mg plus IV ketorolac 30 mg, NOT corticosteroids. 3