SGEM#28: Bang your Head (Steroids for Migraine Headaches)

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Date: 17 March 2013

Case Scenario: A thirty-nine year-old woman known to your emergency department with a long history of migraine headaches presents in her usual way. There is nothing to suggest anything other than her typical migraine headache. You treat her successfully with IV fluids, DHE and metoclopramide. She is feeling much better and is ready for discharge.

Background: More than 10% of people (6% men and 18% women) suffer from migraines. This condition represents a significant source of both medical costs and lost productivity. Direct costs are estimated at ~17 billion dollars a year. There are also indirect costs of about 15 billion dollars a year mainly due to missed work. Up to half of patients presenting to the ED with their migraines will “bounce-back” to the ED in a few days. Dexamethasone has been tried in randomized control trials to prevent bounce-backs. Giuliano et al did a good review on this topic in Postgraduate Medicine last year.

Question: Can dexamethasone prevent migraine patients from bouncing back to the emergency department in the next few days?

Reference: Coleman et al. Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence BMJ 2008;336:1359

Population: Adult patients (>18 yo.) with acute severe migraine headache, meeting reasonable criteria to distinguish migraine from other non-migraine headaches. Seven studies were included in the meta-analysis (n=738)
Intervention: Parenteral dexamethasone (in conjunction with acute abortive therapy); dosing variable
Control: Placebo
Outcome: Primary outcome was recurrence of migraine within 24-72hrs of treatment. Secondary outcome was pain relief scores on 10pt VAS, and adverse events

Results:

Primary Outcome: Recurrence of migraine within 24-72hrs RR=0.74 (95% CI; 0.60-0.90) NNT=9 (95%CI; 6-25)
Secondary Outcome: Pain relief score 10pt VAS was WMD=0.37 (95%CI; -0.20-0.94) NNT (not calculated)
Adverse Events: 6 trials (n=626). Patients treated with dexamethasone were more likely to have dizziness (RR=2.15, 95%CI; 0.98-4.74) but less likely to have nausea (RR=0.70, 95%CI; 0.48-1.02) or “other” adverse events (RR=0.50, 95%CI; 0.30-0.82).

Authors’ Conclusions: “When added to standard abortive therapy for migraine headache, single dose parenteral dexamethasone is associated with a 26% relative reduction in headache recurrence (number needed to treat=9) within 72 hours.”

This review discusses the epidemiology and burden of migraine illness on health care systems and emergency departments. It also illustrates the potential public health and economic benefits of reducing these visits. Recurrent migraine is the second-most important therapeutic goal (after acute pain control) for migraineurs. It is a valuable endpoint from both patient and physician viewpoints. Dexamethasone is a cheap and easy medication to administer parenterally. Its relative risk reduction in early recurrent migraines of 26% with an NNT=9. There were no significant adverse effects and dexamethasone is readily familiar to most emergency physicians. There were some limitations with this review. What “reasonable criteria to distinguish migraine from other headache types” did the authors use?. Was it the International Headache Society criteria for migraine?. There was a failure to reference CONSORT guidelines for reporting studies. There was no assessment for publication bias (funnel plot). Regardless of these limitations, this review, provides information that should help emergency physicians treat these patients more effectively and reduce early recurrent migraine attacks and ED visits.

EBM Point: Consolidated Standards of Reporting Trials or CONSORT Statement. This was an initiative to try and address the problem of inadequate reporting of randomized control trials (RCTs). It consists of a check list of 25 items to standardize the way authors report clinical trial findings. This allows for transparency, critical appraisal and interpretation of the study. It also includes a flow diagram to show what happened to all the participants in the trial.

Washington University in St. Louis has an amazing Emergency Medicine Journal Club started by Capt. Cranium (Dr. Chris Carpenter). They did a great job looking at this literature and can provide more depth than this short podcast.

BEEM Bottom Line: For patients successfully aborted for a migraine attack, a single parenteral dose of dexamethasone ≥15mg will significantly reduce early recurrences (NNT=9) with no significant side effects.

Case Resolution: You discussed dexamethasone treatment with the patient. She decided it was worth a try and you give her 15mg of IV dexamethasone. You plan on checking to see if she re-presents in the next week.

KEENER KONTEST: Last weeks winner was Glenn Paetow. He correctly identified Wagner’s Grading Scale for Diabetic Foot Infections in our Bad to the Bone episode on osteomyelitis. Glenn will be receiving a cool skeptical prize for being so keen.

Be sure to listen to the podcast to hear this weeks Keener Kontest question. Email your answer to TheSGEM@gmail.com Use “Keener Kontest” in the subject line. First one to email me the correct answer wins.