DEXAMETHASONE
PREVENTS RELAPSE AFTER EMERGENCY DEPARTMENT TREATMENT OF ACUTE MIGRAINE: A
RANDOMIZED CLINICAL TRIAL
Innes
GD, et al. Can J Emerg Med 1(1):26, April 1999.
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.
DEXAMETHASONE
DECREASES MIGRAINE RECURRENCE OBSERVED AFTER TREATMENT WITH A TRIPTAN COMBINED
WITH A NONSTEROIDAL ANTI-INFLAMMATORY DRUG.
Krymchantowski
AV, Barbosa JS. Arq Neuropsiquiatr 2001 Sep;59(3-B):708-11.
BACKGROUND
AND OBJECTIVES: Triptans are effective drugs for the acute treatment of
migraine. However, 30-40% of the patients commonly present recurrence before 24
hours therefore requiring another dose. Nonsteroidal anti-inflammatory drugs
(NSAID) such as tolfenamic acid and naproxen sodium combined with sumatriptan
have demonstrated efficacy in reducing recurrence observed with the single use
of this drug. Steroids also have been suggested to treat refractory migraine
and status migranosus. The aim of this study was to evaluate whether patients
presenting frequent recurrence with the combination triptan plus NSAID, would
decrease it with the association of dexamethasone.
METHOD:
Twenty three patients, 17 women and 6 men with migraine according to IHS
criteria were prospectively studied. All patients presented frequent recurrence
(> or= 60%, mean recurrence rate 74,8%) with the single use of sumatritpan
100 mg or zolmitriptan 2,5 mg or rizatriptan 10mg in at least 5 consecutive
attacks, and didn't present a reduction of the recurrence rate superior than
20% with the combination of tolfenamic acid 200 mg or rofecoxib 25 mg in at
least 5 other consecutive attacks (mean recurrence rate 60%). The patients had
to treat 6 consecutive moderate or severe migraine attacks with their usual
combination plus 4 mg of dexamathasone with a maximum of twice a week, and fill
out a diary reporting headache parameters.
RESULTS:
Twenty patients, 16 women and 4 men completed the study. Of those who completed
the study, 11 took rizatriptan plus rofecoxib, 4 rizatriptan plus tolfenamic
acid, 3 zolmitriptan plus rofecoxib, 1 zolmitriptan plus tolfenamic acid and 1
patient took sumatriptan plus tolfenamic acid, having the 20 patients taken as
a third medication, a single tablet of 4 mg of dexamethasone. All patients took
oral formulations and none presented vomiting after that. Among all 20
patients, one female and one male patient presented recurrence in 3 out of the
6 attacks (50%) while the remaining 18 patients revealed recurrence in 1 or 2
treated attacks (mean 23,4%) (p<0,001).
CONCLUSION:
We concluded that the judicious use of oral dexamethasone might be useful for a
limited population of migraine patients still presenting recurrence with the
combination of a triptan and a NSAID. Case-control studies and studies with a
randomized double-blind design are necessary to confirm these observations.