Glucocorticosteroids
In the pediatric patient diagnosed with a refractory migraine, is glucocorticosteriods an effective treatment for the prevention of migraine relapse (return to ED or provider for relapse of the same migraine within 24-72 hours)?
Plain language summary: Based on very low quality evidence, the Migraine in the ED CPG Team makes a conditional recommendation against the use of glucocorticosteriods for either the treatment of acute migraine headache, or the prevention of migraine relapse.
Literature synthesis: Huang et al. (2013) conducted a sound systematic review with meta-analysis on eight RCTs that evaluated this question (See Table 1). For the outcome prevention of relapse of migraine headache, treatment with dexamethasone had the absolute effect of preventing relapse in 11 of 100 subjects (range 5-15 fewer). It did not have a significant treatment effect on the outcome total headache resolution (4 more subjects of 100 subjects had total headache resolution after being treated with dexamethasone, but the range is form 2 fewer to 12 more total headache resolutions per 100 subjects) The only adverse event that was significantly different between treatment groups was dizziness. It occurred more frequently in the group treated with dexamethasone. Dexamethasone had the absolute effect of causing dizziness in 3 of 100 subjects (range 0-12 more). Although the results of the meta-analysis are promising, the characteristics of patients who would benefit from glucocorticosteriods are not clear. Long-term effects of chronic glucocorticosteriods use were not evaluated, nor were the appropriate doses of glucocorticosteriods determined.
The evidence is graded as very low quality evidence due to different doses of dexamethasone (inconsistency) all of the studies were performed in adults (indirectness), and finally in the combined studies there are small number of events, (imprecision). The results of a case series reported by (Legault, Eisman, and Shevell (2011) did not find a difference in “bounce” backs in children treated with steroids, versus those who were not. Larger, prospective studies are needed to clarify the migraine recurrence and treatments that are efficacious to prevent migraine headache and recurrence.
See Appendix F for the full Critically Appraised Topic (CAT).
These pathways do not establish a standard of care to be followed in every case. It is recognized that each case is different, and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare a pathway for each. Accordingly, these pathways should guide care with the understanding that departures from them may be required at times.