Migraine - A Better Steroid than Dexamethasone?

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Methylprednisolone acetate (MPA) 160mg IM was not better than dexamethasone 10mg IM (both given with metoclopramide 10mg IM) for reducing headache days in the week following an ED visit in migraine patients.

Why does this matter?
Dexamethasone has been found to reduce headache recurrence in migraine patients, NNT = 9. Would a longer acting steroid be even better than dexamethasone, which has anti-inflammatory effects for roughly 72 hours?

Doc, I still have a headache
This was a RCT including 207 patients with moderate to severe migraine comparing metoclopramide 10mg IM in each group combined with either dexamethasone 10mg IM or MPA (Depo-Medrol) 160mg IM (which has effects lasting 14 days). They found no difference in the primary outcome of headache days the following week: 3 in the dex group and 3.3 in the MPA group, not statistically significantly different. None of the secondary outcomes were different either. More patients had injection site reactions in the MPA group. It was surprising how many patients in both groups had persistent headache in the week following an ED visit. Hundreds of patients were excluded as having possible secondary cause of headache or non-migraine cause. Also, patients in the MPA group had baseline headache a median 72h vs median 48h in the dex group. Maybe the MPA group was at a disadvantage due to chance imbalance in randomization. So, how does this help us? First, I am not going to use MPA for headache. It’s not better than dexamethasone and causes more pain at the injection site. Next, we can tell patients that most will not be headache free the following week and set realistic expectations.

Source
A Randomized Trial of a Long-Acting Depot Corticosteroid Versus Dexamethasone to Prevent Headache Recurrence Among Patients With Acute Migraine Who Are Discharged From an Emergency Department. Ann Emerg Med. 2018 Nov 15. pii: S0196-0644(18)31288-5. doi: 10.1016/j.annemergmed.2018.09.028. [Epub ahead of print]

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