What prednisone dosing regimen is appropriate as rescue therapy for a severe migraine in a 65‑year‑old, 85‑kg (188‑lb) sodium‑sensitive woman?

Prednisone Dosing for Severe Migraine Rescue Therapy

For a 65-year-old, 188-lb woman with severe migraine requiring rescue therapy, prednisone 40 mg orally once daily for 2 days is the appropriate regimen, but only after first-line acute therapies (NSAIDs, triptans, or their combination) have failed or are contraindicated. 1

Position of Corticosteroids in Migraine Treatment Algorithm

• Corticosteroids are not first-line therapy for acute migraine—NSAIDs (naproxen 500–825 mg, ibuprofen 400–800 mg) or triptans (sumatriptan 50–100 mg) should be tried first. 1
• Prednisone is reserved as rescue therapy for severe attacks unresponsive to standard abortive medications, status migrainosus (headache lasting >72 hours), or medication-overuse headache detoxification. 2, 1
• The strongest evidence supports corticosteroids for preventing headache recurrence after emergency-department treatment and for breaking prolonged migraine attacks, not as routine first-line therapy. 3, 4

Evidence-Based Dosing Regimen

• Oral prednisone 40 mg once daily for 2 days is the most commonly studied outpatient regimen and has demonstrated efficacy in detoxifying patients with medication-overuse headache and reducing recurrence. 5, 6
• Alternative regimens include dexamethasone 10 mg IV as a single dose in the emergency department, which showed a median absolute risk reduction of 30% for 24-hour headache recurrence in pooled analysis. 4
• Short tapering courses (e.g., prednisone 60 mg × 1 day, 40 mg × 1 day, 20 mg × 1 day) have also been used for status migrainosus, though evidence is less robust than for the 2-day fixed-dose regimen. 7, 3

Clinical Context for This Patient

• Sodium sensitivity is not a contraindication to short-course corticosteroids—the 2-day duration minimizes fluid retention and hypertension risk. 3
• At 188 lbs (85 kg), weight-based dosing is not required; fixed-dose prednisone 40 mg is appropriate for adults regardless of body weight. 5, 6
• Age 65 does not alter the dosing regimen, though monitoring for hyperglycemia and blood pressure elevation is prudent in older adults. 3

Critical Frequency Limitation

• Corticosteroids can be administered safely up to 6 times annually for migraine rescue therapy—more frequent use raises concerns for cumulative adverse effects (osteoporosis, hyperglycemia, immunosuppression). 3
• If this patient requires corticosteroid rescue more than twice in 3 months, immediate initiation of preventive therapy (beta-blockers, topiramate, CGRP monoclonal antibodies) is mandatory to break the cycle of frequent severe attacks. 2, 1

When Prednisone Is Most Beneficial

• Patients with status migrainosus (continuous headache >72 hours despite treatment) derive the greatest benefit from corticosteroid therapy. 3, 4
• Patients with history of recurrent headaches after emergency-department treatment (up to 87% recurrence rate) benefit from adjunctive corticosteroids to reduce 24–72 hour recurrence. 4
• Patients undergoing medication-overuse headache detoxification (stopping daily triptans or NSAIDs) benefit from prednisone to mitigate withdrawal symptoms and headache worsening during the first 6 days. 5

Alternative Parenteral Option

• If the patient presents to an emergency department or urgent-care setting with IV access, dexamethasone 10 mg IV as a single dose is an alternative to oral prednisone and has comparable efficacy. 6, 4
• Dexamethasone has a longer half-life than prednisone, potentially providing more sustained benefit for preventing recurrence. 4

Contraindications and Precautions

• Avoid corticosteroids in patients with uncontrolled diabetes, active infection, or immunosuppression—the 2-day course is generally safe but requires clinical judgment in these populations. 3
• Monitor blood glucose and blood pressure during and after the 2-day course, especially in patients with pre-existing hypertension or diabetes. 3

What Not to Do

• Do not prescribe prednisone as first-line therapy for routine migraine attacks—this bypasses evidence-based acute treatments (NSAIDs, triptans) and exposes patients to unnecessary corticosteroid risks. 1
• Do not use corticosteroids more than 6 times per year—frequent use signals inadequate preventive therapy and increases cumulative adverse-effect risk. 3
• Do not substitute corticosteroids for preventive therapy—if this patient has ≥2 migraine attacks per month causing disability ≥3 days, or uses acute medications >2 days per week, preventive therapy (propranolol, topiramate, CGRP monoclonal antibodies) is indicated. 2, 1

Practical Prescription

• Prednisone 40 mg tablets: Take 1 tablet by mouth once daily for 2 days. 5, 6
• Instruct the patient to take with food to minimize gastrointestinal upset. 3
• Provide rescue instructions: if headache persists after 2 days, the patient should seek urgent evaluation rather than continuing corticosteroids. 3