Hostname: page-component-cd9895bd7-gbm5v Total loading time: 0 Render date: 2024-12-28T20:32:01.210Z Has data issue: false hasContentIssue false
  • English
  • Français

Dexamethasone prevents relapse after emergency department treatment of acute migraine: a randomized clinical trial

Published online by Cambridge University Press:  21 May 2015

Grant D. Innes ,
Iain Macphail ,
Edward C. Dillon ,
Cathy Metcalfe  and
Min Gao
Grant D. Innes
Affiliation:
Department of Emergency Medicine, St. Paul’s Hospital, and The Centre for Health Evaluation and Outcome Sciences, Vancouver, BC
Iain Macphail
Affiliation:
Department of Emergency Medicine, Royal Columbian Hospital, New Westminster, BC
Edward C. Dillon
Affiliation:
Department of Pharmacy, Royal Columbian Hospital, New Westminster, BC
Cathy Metcalfe
Affiliation:
Department of Emergency Medicine, Royal Columbian Hospital, New Westminster, BC
Min Gao
Affiliation:
The Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, BC

Abstract:

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Objective:

To determine whether the addition of intravenous dexamethasone to standard emergency department (ED) migraine therapy would decrease the incidence of severe recurrent headache 24 to 48 hours after initial treatment.

Methods:

Patients aged 19 to 65 years whose headache was severe enough to require parenteral therapy and who met International Headache Society migraine criteria were eligible for this randomized, double-blind trial. The study was conducted in the ED of 2 community hospitals, 1 of which was a tertiary referral centre. Exclusion criteria included pregnancy, focal findings, fever, meningismus, allergy to the study drug, active peptic ulcer disease and diabetes mellitus. Demographic and clinical data, including headache severity, were recorded. After abortive therapy (antiemetics, intravenous nonsteroidal agents, dihydroergotamine or opioids), blinded nurses administered dexamethasone (24 mg intravenously) or placebo. Patients recorded headache severity on a Visual Analogue Scale (VAS) at time T = 0, T = 30 minutes and T = 60 minutes and at discharge. They were contacted 48 to 72 hours later and asked whether they had suffered a recurrence of their headache, categorized as class A (severe, provoking another physician visit), class B (severe, interfering with daily activity but not provoking a physician visit), class C (mild, requiring self-medication but not limiting activity) or class D (mild, requiring no treatment). Results: Two of 100 patients were lost to follow-up, leaving 98 in the study sample. Placebo recipients were more likely to be female; other baseline characteristics were similar between groups. Median VAS pain score was 83 mm on ED arrival, 35 mm after initial treatment and 12 mm on discharge. At follow-up, 65 of 98 patients had suffered headache recurrence. In the placebo versus dexamethasone groups, respectively, the results were 11 versus 0 in class A, 11 versus 9 in class B, 7 versus 11 in class C and 4 versus 12 in class D. Regarding the primary outcome, 9 of 49 dexamethasone patients (18%) and 22 of 49 placebo patients (45%) had severe (classes A and B) recurrent headache (odds ratio 0.28; 95% CI, 0.11 to 0.69; p = 0 .005).

Conclusions:

Migraine recurrence is common after “successful” ED treatment. Inflammation may be a critical factor in migraine genesis. Intravenous dexamethasone decreases the incidence of severe recurrent headache after ED treatment and should be offered to patients thought to be at risk of recurrent headache.

Keywords

migraineheadacheanalgesiaemergency departmentcorticosteroidsdexamethasone
Type
EM Advances • Progrès de la MU
Information
Canadian Journal of Emergency Medicine , Volume 1 , Issue 1 , April 1999 , pp. 26 - 33
Copyright
Copyright © Canadian Association of Emergency Physicians 1999

References

1.Klapper, JA, Stanton, JS.Ketorolac (IM) versus dihydroergotamine and metoclopramide (IV) in the treatment of migraine headache. Headache 1991;31:523–4.CrossRefGoogle Scholar
2.Duarte, C, Dunaway, F, Turner, L.Ketorolac versus meperidine and hydroxyzine in the treatment of acute migraine headache: a randomized, double blind trial. Ann Emerg Med 1992;21:1116–21.CrossRefGoogle Scholar
3.Stiller, J.Management of acute intractable headaches using intravenous therapy in an office setting. Headache 1992;32:514–5.CrossRefGoogle Scholar
4.Tek, DS, McClellan, DS, Olshaker, JS.A prospective, doubleblind study of metoclopramide for the control of migraine in the emergency department. Ann Emerg Med 1990;19:1083–7.CrossRefGoogle ScholarPubMed
5.Ellis, GL, Delaney, J, DeHart, DA, Owens, A.The efficacy of metoclopramide in the treatment of migraine headache. Ann Emerg Med 1993;22:191–5.CrossRefGoogle ScholarPubMed
6.Klapper, J, Stanton, J.The emergency treatment of acute migraine headache: a comparison of intravenous dihydroergotamine, dexamethasone, and placebo. Cephalgia 1991;2(Suppl 2):159–60.CrossRefGoogle Scholar
7.Lane, PL, McLellan, BA, Baggoley, CJ.Comparative efficacy of chlorpromazine and meperidine with dimenhydrinate in migraine headache. Ann Emerg Med 1989;18:360–5.Google Scholar
8.Bell, R, Montoya, D, Shuaib, A, Lee, MA.A comparative trial of three agents in the treatment of acute migraine headache. Ann Emerg Med 1990;19:1079–82.CrossRefGoogle ScholarPubMed
9.Callaham, M, Raskin, N.A controlled study of dihydroergotamine in the treatment of acute migraine headache. Headache 1986;26:168–71.CrossRefGoogle ScholarPubMed
10.Saadah, HA.Abortive migraine therapy in the office with dexamethasone and prochlorperazine. Headache 1994;34:366–70.CrossRefGoogle ScholarPubMed
11.Stiell, IG, Dufour, DG, Moher, D, Yen, M, Beilby, WJ, Smith, NA.Methotrimeprazine versus meperidine and dimenhydrinate in the treatment of severe migraine: a randomized, controlled trial. Ann Emerg Med 1991;20:1201–5.Google Scholar
12.Jones, EB, Gonzales, ER, Boggs, JG, Grillo, JA.Safety and efficacy of rectal prochlorperazine for the treatment of migraine in the emergency department. Ann Emerg Med 1994;24:237–41.CrossRefGoogle ScholarPubMed
13.Gallagher, RM.Emergency treatment of migraine. Headache 1986;26:74–5.CrossRefGoogle Scholar
14.Klapper, JA, Stanton, JS.Clinical experience with patient administered subcutaneous dihydroergotamine in refractory headaches. Headache 1992;32:21–3.Google Scholar
15.Saadah, HA.Abortive headache therapy with intramuscular dihydroergotamine. Headache 1992;32:18–20.CrossRefGoogle ScholarPubMed
16.Jauslin, P, Goadsby, PJ, Lance, JW.The hospital management of severe migrainous headache. Headache 1991;31:658–60.CrossRefGoogle ScholarPubMed
17.Robbins, L, Remmes, A.Outpatient repetitive intravenous DHE. Headache 1992;32:455–8.CrossRefGoogle Scholar
18.The Multinational Oral Sumatriptan and Cafergot Comparative Study Group. A randomized, double-blind comparison of sumatriptan and cafergot in the acute treatment of migraine. Eur Neurol 1991;31:314–22.Google Scholar
19.The Subcutaneous Sumatriptan International Study Group. Treatment of migraine attacks with sumatriptan. N Engl J Med 1991;325:316–21.CrossRefGoogle Scholar
20.Silberstein, SD, Lipton, RB.Overview of diagnosis and treatment of migraine. Neurology 1994;44(Suppl 7):S6–16.Google ScholarPubMed
21.Raskin, NH.Acute and prophylactic treatment of migraine. Neurology 1993;43(Suppl 3):S39–42.Google ScholarPubMed
22.Neighbor, ML.Sumatriptan: a new treatment for migraine. West J Med 1993;159:597–8.Google ScholarPubMed
23.Bateman, DN.Sumatriptan. Lancet 1993;341:221–3.Google Scholar
24.Dahlof, C, Ekbom, K, Persson, L.Clinical experiences from Sweden on the use of subcutaneously administered sumatriptan in migraine and cluster headache. Arch Neurol 1994;51:1256–61.CrossRefGoogle ScholarPubMed
25.Cameron, JD, Lane, PL, Speechley, M.Intravenous chlorpromazine vs. intravenous metoclopramide in acute migraine headache. Acad Emerg Med 1995;2:597–602.CrossRefGoogle ScholarPubMed
26.Larkin, GL, Prescott, JE.A randomized, double-blind, comparative study of the efficacy of ketorolac versus meperidine in the treatment of severe migraine. Ann Emerg Med 1992;21:919–24.CrossRefGoogle ScholarPubMed
27.Moskovitz, MA.Neurogenic inflammation in the pathophysiology and treatment of migraine. Neurology 1993;43(Suppl 3):S16–20.Google Scholar
28.Buzzi, MG, Moskowitz, MA.Evidence for 5-HT1B/1D receptors mediating the antimigraine effect of sumatriptan and dihydroergotamine. Cephalgia 1991;11:165–8.Google Scholar
29.Lance, JW.Current concepts of migraine pathogenesis. Neurology 1993;43(Suppl 3):S11–5.Google ScholarPubMed
30.Goadsby, PJ, Gundlach, AL.Localization of 3H-dihydroergotamine-binding sites in the cat central nervous system: relevance to migraine. Ann Neurol 1991;29:91–4.CrossRefGoogle ScholarPubMed
31.Rapoport, AM, Silberstein, SD.Emergency treatment of headache. Neurology 1992;42(Suppl 2):43–4.Google ScholarPubMed
32.Saper, J.Daily chronic headache. Neurol Clin 1990;8:891–901.Google Scholar
33.Schulman, EA, Silberstein, SD.Symptomatic and prophylactic treatment of migraine and tension headache. Neurology 1992; 42(Suppl 2):16–21.Google Scholar
34.Lobo, RL, Landy, S.Recommendations for the emergency treatment of migraine headache. J Tenn Med Assoc 1994;Feb:53–4.Google Scholar
35.Chan, AT, O’Brien, ME.Hypersensitivity to dexamethasone. BMJ 1993;306:109.CrossRefGoogle ScholarPubMed