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Editorial
Cephalalgia
0(0) 1–2
Reducing migraine return with ! International Headache Society 2015
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DOI: 10.1177/0333102414566203
cep.sagepub.com
to improve migraine care

W Jeptha Davenport

Migraine treatment in the emergency department is a although the conclusion of one individual study (2) was
scenario patient and physician alike would prefer to negative in a primary outcome, the secondary outcome
avoid. With severe pain, aversion to light and sound, in a subset of patients was positive, and leads to clas-
nausea, vomiting, and a desire to achieve sleep, a sification under ‘favorable outcomes’ for the treatment
migraine sufferer would naturally choose less provoca- (1 (Table 1)). The data sets retrieved and reviewed point
tive surroundings, if only relief could be had elsewhere. in the same direction: For the migraine attack that
For her emergency physician, the patient with migraine resists other therapy, corticosteroids (most often a
almost never has a life-threatening, but a life-interrupt- single dose of 10 mg intravenous dexamethasone,
ing, episode, one that lasts hours to days and responds Figure 5 (1)) tend to reduce the recurrence rate and
inconsistently to interventions. Then, at discharge, after severity of subsequent headaches. Opportunities to
success and relief appear together, the question looms expand reviewable data abound: The number of
for both patient and physician, will the migraine patients for whom data have been captured for this
return? systematic review and analysis (just under 4000) must
Just as the most common rank of a graduating class be a figure many orders of magnitude lower than those
(minimum size one) is valedictorian, any given visit to exposed over six decades to treatment outside of experi-
an emergency department for headache is most likely be mental settings. The conclusion based on available data
the first, but it is repeated visits, repetitive, treatment- is promising: Short-term, high-dose corticosteroid use
resistant migraine attacks, that raise the signal that a now justifiably retains its ‘‘time-honoured place’’ (3) in
migraine sufferer is not managing well. One possible the toolkit for the treatment of prolonged migraine
tool to delay headache recurrence after a prolonged attacks—the accumulation of evidence supports current
migraine attack is the class of corticosteroids (denoting practice. Some of the studies identified may not be
any naturally occurring or analog glucocorticoid or widely generalizable because of the adjuvant role of
mineralocorticoid). In their systematic review in the the corticosteroid, with primary treatments that may
current issue of Cephalalgia, Woldeamanuel and co- not be applied in all or most cases (e.g. metoclopramide
authors (1) searched the entirety of accessible medical and diphenhydramine in Friedman et al. (4)).
literature from the time of production of synthetic cor- Discouraging for patients and clinicians seeking all
ticosteroids to the present to identify relevant the answers today, but encouraging for those keen to
data about a common pharmacological treatment of tackle today’s questions, such limitations show the
migraine in emergency departments and similar set- work to be done: Increasing the number of attack-
tings. The authors used multiple search strategies of and-treatment pairs studied, improving reporting and
published and unpublished sources, evaluated study accessibility of data, and comparing routes and particu-
quality, and abstracted information to allow for lar agents head-to-head would refine subsequent rec-
meta-analysis using current methods. The report of ommendations regarding corticosteroids. The question
this exhaustive search should be of interest to headache
physicians because it contains both encouraging and Departments of Clinical Neurosciences and Medical Genetics; Hotchkiss
discouraging news. Brain Institute, Cumming School of Medicine, University of Calgary,
In 60 years’ data, only 25 studies appear to address Canada
this clinical scenario, corticosteroid treatment of
migraine attack in acute care settings. For the reader’s Corresponding author:
W Jeptha Davenport, Calgary Headache Assessment & Management
convenience and further study, these 25 studies are Program, South Health Campus, 4448 Front St. S.E., Calgary, AB T3M
summarized by the authors in Table 1 (1). The identi- 1M4, Canada.
fied studies’ sum is greater than the parts; for example, Email: jeptha.davenport@albertahealthservices.ca
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of route is especially important as it often defines the emergency interventions provided, and adjustment of
treatment setting: If parenteral treatments are required, future rescue plans accordingly. The sort of care
their delivery is likely to remain in an acute-care setting; recommended here and by the authors (1) would be
if enteral treatments are equally effective and ade- expected of a headache specialist or headache clinic.
quately tolerated by the gut, they may be prescribed Those who focus clinically on patients with migraine
in advance and used by the patient in more comfortable should aim to define and promote adequate tools for
surroundings. patients at all stages in this chronic disease with epi-
Between acute abortive migraine therapy (for which sodic manifestations: preventively, acutely, in-need of
evidence suggests that intravenous dexamethasone is rescue, and, in a window enlarged by judicious cortico-
not superior to placebo (5)) and preventive migraine steroid use, the authors successfully argue, post-rescue.
therapy (for which corticosteroids have not been exten- The best care of migraine attacks leading to emergency
sively used, studied or yet led to accessible results care may now include delaying the recurrence of
(namely, registered study NCT00915473, examining the next attack to allow for transfer of care (during
methylprednisolone injection via greater occipital remission) to the headache specialist.
nerve block, and NCT01813591, on adrenocortico-
tropic hormone injection) (6,7)), rescue therapy for
Conflict of interest
migraine with the goal of reducing future short-term
recurrence may include a corticosteroid. The fact that None declared.
a particular intervention (corticosteroid) may be effect-
ive as a rescue therapy but not as an acute abortive References
therapy or prophylactic suggests that the underlying 1. Woldeamanuel YW, Rapoport AM and Cowan RP. The place
pathophysiology differs, or that the effects of the inter- of corticosteroids in migraine attack management: A 65-year
vention are specific to the time frame of the condition. systematic review with pooled analysis and critical appraisal.
Cephalalgia 2015. DOI: 10.1177/0333102414566200.
The authors suggest the latter, noting the long biologic
2. Kelly AM, Kerr D and Clooney M. Impact of oral dexa-
half-life of dexamethasone, for example (1). The methasone versus placebo after ED treatment of migraine
authors suggest elsewhere that short, tapering doses with phenothiazines on the rate of recurrent headache: A
of corticosteroids may be used safely six times annually, randomised controlled trial. Emerg Med J 2008; 25: 26–29.
based on expert recommendations (8). Knowing that 3. Worthington I, Pringsheim T, Gawel MJ, et al. Canadian
the absolute risk reduction falls rapidly from one day Headache Society Guideline: Acute drug therapy for
to three days post-headache ((1) Figure 3a) and that the migraine headache. Can J Neurol Sci 2013; 40 (5 Suppl
number needed to treat to avoid recurrence at 72 hours 3): S1–S80.
is 10 ((1) Figure 3b), with a treatment with course limits 4. Friedman BW, Greenwald P, Bania TC, et al. Randomized
on repetition for any individual patient, the risks trial of IV dexamethasone for acute migraine in the emer-
(however small) and benefits need to be considered. gency department. Neurology 2007; 69: 2038–2044.
5. Orr SL, Aubé M, Becker WJ, et al. Canadian Headache
The benefit accounting for dexamethasone, for exam-
Society systematic review and recommendations on the
ple, should include low cost and near-universal avail- treatment of migraine pain in emergency settings.
ability (found on the World Health Organization Cephalalgia. Epub ahead of print 29 May 2014.
(WHO) Model Lists of Essential Medicines (9)), but it 6. The Repository of Registered Migraine Trials: RReMiT
still must be serve a purpose. Database, www.acttion.org/rremit, (accessed 13
The key to justifying the use of a medication that November 2014).
may not be especially helpful acutely or long term is 7. Dufka FL, Dworkin RH and Rowbotham MC. How
that it is one that buys time in between. (This time transparent are migraine clinical trials? Repository of
comes at the expense of hopefully small risks, the Registered Migraine Trials (RReMiT). Neurology 2014;
data suggest.) In the days after discharge from an 83: 1372–1381.
acute care facility with corticosteroid (among other 8. Woldeamanuel YW, Rapoport AM and Cowan RP. What
is the evidence for the use of corticosteroids in migraine?
treatments) for prolonged and therapy-resistant
Curr Pain Headache Rep 2014; 18: 464–468.
migraine attack, the patient needs continuing care. 9. World Health Organization. WHO model lists of essential
This care should include review of any modifiable medicines, 18th ed., http://www.who.int/medicines/publi-
factors leading to the index attack, a re-assessment of cations/essentialmedicines/en/ (April 2013, accessed 13
the efficacy and availability of acute abortive therapies, November 2014).
a re-evaluation, or strong consideration, of prophylac-
tic therapy, documentation as to the results of the