Steroids in Headache: A Comprehensive Review of Recent Research

Priyanka V Kashyap 1, Sounak Chabri 1

Main research Goal: 

• The efficacy of steroid use in primary headache: migraine without aura, tension headache, and cluster headache 

Why is this important to emergency medicine practice:

• Headache is one of the bread and butter cases in the ER, with headache being the most frequently reported neurological complaint and affects 50% of women in the general population during their lifetime. Everyone has their cocktail, but no one I’ve worked with includes steroids in theirs. If it can decrease symptoms, decrease return of symptoms administration in the ER could really benefit our patients. 

• 40 to 70 % efficacy in treatment in most studies, and mistreatment or undertreatment results in recurrent ER visits which puts a strain on our ERs and the patients 

Study Design:

• Systematic review 

Methods:

• Population

  • 25 studies 

  • N = 2989, 37.5 median age, male to female ration 1:4.23 

• Intervention or exposure 

  • Steroids vs placebo 

  • Parenteral dexamethasone was found to be the most commonly administered steroid (56%) at a median single dose of 10 mg (range being 4–24 mg).

• Outcome measure 

  • Decrease in symptom severity and recurrence 

Results:

• Key Findings 

  • 76% of studies showed favoring benefits, non inferior outcomes were showing in 24%

  • Median absolute reduction of risk was around 30%, (6% to 48%), 11% (6% to 48.6%) for 24h and 72 hr of recurrence of headache 

  • higher disability with status migrainosus, incomplete relief in pain and history of previous headache recurrence predicted outcome favorability 

  • One study failed to show and benefit of long acting depot corticosteroid (160mg of methylprednisolone acetate IM) over dexamethasone (10mgIM) in migraine patients with moderate and severe intensity 

  • Dexamethasone in reduction of migraine recurrence Neill A et al. Emerg Med J 2013. 13: 2 metaanalysis with reviews of 7 RCTs total of 738 and 742 patients each with the outcome of headache occurrence in 24 hours have a reduction in headache with a RR of .74 and .87 

  • Dexamethasone in parenteral form for severe migraine: Meta-analysis of randomized controlled trials in recurrence prevention. Colman et al. BMJ 2008. 14: 7 double blind RCTs, dexamethasone and placebo had similar pain reduction, but dexamethasone efficacy was more than placebo in recurrence reduction RR: .74 

  • Steroids in recurrence of acute and also severe migraine headaches prevention: Meta-analysis. Huang et al. Eur J Neurology 2013. 8 studies and 905 patients , add on steroids with the standard therapy reduced rate of recurrence past 24-72 hours with a RR: .71 with a confidence interval .59 to .86 , no difference between IV and PO steroids, 

  • Steroids vs GON injections for cluster headaches: a majority of patients responded to both prednisone and GON injections with righ responders to oral steroids (82.7% to 62.4%)

  • 116 patients with episodic cluster headaches had a 5 day 100mg po prednisone with a 20mg taper for 3 days + standard verapamil had a mean of 7.1 attacks in the first week compared to the placebo of just verapamil with a p of .002

  • Medication overuse headache, mainly with TCAs, benzos, and reglan and showed a  significant decrease in severity of headaches , 85% had relief in frequency and non presented with severe headache in the first 6 days , one double blind RCT however failed to show any statistically significant benefit here though 

  • Were the results statistically significant 

  • In most studies in the trail 

Discussion and conclusion 

• Did the authors discuss strengths and limitation of the study, was there any limitations not addressed 

  • Did not discuss limitations. With so many studies used they did not go into inclusion or exclusion criteria for studies used and thus this study could be cherry picked. 

• Were the conclusions drawn by the author supported by the data 

  • Yes. Basically reduction in pain was modest but the greatest benefit came from recurrence of symptoms 

• How do the findings compare to previous research in the same area 

  • Corroborates previous studies 

Impact on clinical practice 

• You can add 10mg IV decadron to patients that come in with headaches. If cluster is suspected you can give 5 days of 100mg po prednisone with a 20mg taper for 3 days and advise them to go to their PCP to discuss prophylaxis with verapamil. 

Summary by Dr. Kenneth Appel PGY-2 , 2025