Steroid Use for Cephalea (Headache)
Steroids are not first-line treatment for routine headaches but serve a critical role in specific scenarios: status migrainosus (prolonged severe migraine), cluster headache bridge therapy, and medication overuse headache detoxification. 1
When to Use Steroids in Headache Management
Primary Indications
Status migrainosus: Methylprednisolone 40-60 mg daily as single or divided doses for 3-10 days is the standard approach for severe prolonged migraine attacks lasting beyond 72 hours 1
Cluster headache bridge therapy: Prednisone at high doses (1 mg/kg/day, maximum 60 mg daily) for 4 days followed by 10-mg taper every 2 days provides temporary relief while preventive medications (verapamil, lithium) take effect 2, 3
Medication overuse headache: Short courses of oral corticosteroids facilitate detoxification from rebounding analgesics during the withdrawal period 4
Evidence for Acute Migraine
Single-dose intravenous dexamethasone (10 mg) reduces 24-hour headache recurrence by 30% absolute risk reduction and 72-hour recurrence by 11% when added to standard abortive therapy 5
Parenteral dexamethasone is most commonly used at median single dose of 10 mg (range 4-24 mg) in emergency department settings 5
However, the American Academy of Family Physicians states there are no good studies documenting steroid efficacy in routine acute migraine attacks 1
Critical Frequency Limitation
Corticosteroids can be administered safely up to 6 times annually maximum—exceeding this frequency risks systemic complications including glucose metabolism abnormalities, hypertension, peptic ulcer, and mood alterations. 1
Monitoring Requirements for Side Effects
Hyperglycemia Management
Blood glucose monitoring should be performed four times daily (fasting and 2 hours after each meal) during steroid therapy, with target range 90-180 mg/dL (5-10 mmol/L) 6
Peak hyperglycemic effects occur 6-9 hours after steroid administration, making afternoon glucose monitoring particularly important 6
For significant hyperglycemia, start NPH insulin at 0.3-0.5 units/kg/day given in the morning to match the pharmacokinetics of glucocorticoids 6
As steroid doses are reduced, insulin doses must be proportionally decreased to avoid hypoglycemia—this is a common pitfall 6
Hypertension Monitoring
Blood pressure should be monitored regularly during steroid therapy, particularly in elderly patients who have increased risk of fluid retention and hypertension 7
The FDA label warns that corticosteroids can cause fluid retention and electrolyte disturbances, necessitating dietary salt restriction and potassium supplementation 7
Contraindications and Precautions
Absolute Contraindications
- Active systemic fungal infections 7
- Administration of live or live-attenuated vaccines during immunosuppressive steroid doses 7
- Active ocular herpes simplex (risk of corneal perforation) 7
Relative Contraindications Requiring Monitoring
Uncontrolled diabetes mellitus: Steroids significantly worsen glycemic control through multiple mechanisms (impaired insulin secretion, increased insulin resistance, enhanced hepatic gluconeogenesis) 1, 6
Active peptic ulcer disease: Concomitant NSAID use with corticosteroids increases gastrointestinal bleeding risk 7
Severe uncontrolled hypertension: Steroids cause sodium retention and fluid accumulation 7
Psychiatric conditions: Corticosteroids can cause psychiatric derangements ranging from euphoria and insomnia to severe depression and frank psychotic manifestations 7
Special Populations
Latent tuberculosis: Reactivation may occur; patients require chemoprophylaxis during prolonged steroid therapy 7
Hepatitis B carriers: Screen before initiating immunosuppressive steroid treatment due to reactivation risk 7
Patients with varicella or measles exposure: Non-immune patients taking corticosteroids can develop serious or fatal courses; prophylaxis with immune globulin may be indicated 7
Common Pitfalls to Avoid
Using only fasting glucose to monitor steroid-induced hyperglycemia: This misses the peak hyperglycemic effect occurring in afternoon/evening 6
Failing to taper insulin when steroids are reduced: This leads to hypoglycemia 6
Prescribing steroids more than 6 times annually: This increases risk of systemic complications 1
Underdosing steroids: For cluster headache, the recommended dose is 1 mg/kg/day (maximum 60 mg), not the commonly prescribed methylprednisolone dose pack which provides inadequate total steroid exposure 2
Long-term steroid use without ophthalmic monitoring: Steroids can cause posterior subcapsular cataracts, glaucoma, and increased intraocular pressure; monitoring should occur if therapy exceeds 6 weeks 7
Alternative First-Line Treatments
For acute migraine: NSAIDs (aspirin, ibuprofen, naproxen) for mild-moderate attacks; triptans (sumatriptan, rizatriptan) for moderate-severe attacks 1
For cluster headache prevention: Verapamil is first-choice preventive, not steroids which serve only as bridge therapy 3
For chronic headache prevention: Propranolol 80-240 mg/day, topiramate, or candesartan require 2-3 months to assess efficacy 1