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Dexamethasone Dosing for Patients with Migraine Headache

November 28, 2023

Written by Jason Lesnick

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This RCT found no differences between high dose (16 mg) and low dose (4 mg) IV dexamethasone in patients who presented to EDs with migraine headaches. 

More dex = longer relief? Not so fast my friend…   
We have previously referenced that dexamethasone has been found to reduce headache recurrence in migraine patients with a NNT = 9. The authors of this double-blind RCT compared 4 mg to 16 mg of IV dexamethasone in addition to 10 mg IV metoclopramide in 209 patients (86% of whom identified as women) who presented to two academic EDs in New York. Patients were eligible if their headaches were classified as moderate or severe in intensity and they met migraine criteria, as defined by the International Classification of Headache Disorders, 3rd edition. 

The authors measured pain intensity for up to 2 hours in the ED and by telephone 2 and 7 days later. The primary outcome was sustained headache relief, while secondary outcomes included headache relief within 2 hours and the number of headache days during the subsequent week. 

The authors found 35/102 (34%) of patients in the 4 mg arm achieved sustained headache relief compared to 42/102 (41%) of those in the 16 mg arm, a 7% difference (95%CI -6% to 20%). Within 2 hours, headache relief occurred in 77/104 (74%) of the low-dose dex group and 82/105 (78%) of the high-dose group, a 4% difference (95% CI -8% to 16%). After discharge, both groups reported a median of 2 headache days in the week after discharge. The low dose group had 25th and 75th percentile responses of 1 and 5 days while the high dose group had 0 and 4 days as their 25th and 75th percentiles, mean difference 0.4 (95%CI -0.3 to 1.2). 

This study ended early after a pre-planned interim analysis where the definition of futility (<10% absolute difference) was met, and the data monitoring committee recommended that enrollment be stopped. 

How will this change my practice?
As someone who has suffered from classical migraines since I was a child, I am interested in migraine treatment. I am always in favor of providing the lowest efficacious dose possible to decrease complications. As such, I will likely be ordering 4 mg IV dexamethasone instead of the 10 mg I had been using previously in these patients, unless I see more convincing data.

Randomized Trial Comparing Low- vs High-Dose IV Dexamethasone for Patients With Moderate to Severe Migraine. Neurology vol. 101,14 (2023): e1448-e1454. doi:10.1212/WNL.0000000000207648

What are your thoughts?