Steroids for preventing recurrence of acute severe migraine headaches: a meta-analysis

Managing and Preventing Migraine in the Emergency Department: A Review

Migraine is a leading cause of disability worldwide, and acute migraine attacks are a common reason for patients to seek care in the emergency department (ED). There have been recent advancements in the care of patients with migraine, specifically emerging evidence for nerve blocks and new pharmacological classes of medications like gepants and ditans. This article serves as a comprehensive review of migraine in the ED, including diagnosis and management of acute complications of migraine (eg, status migrainosus, migrainous infarct, persistent aura without infarction, and aura-triggered seizure) and use of evidence-based migraine-specific treatments in the ED. It highlights the role of migraine preventive medications and provides a framework for emergency physicians to prescribe them to eligible patients. Finally, it evaluates the evidence for nerve blocks in the treatment of migraine and introduces the possible role of gepants and ditans in the care of patients with migraine in the ED.

Randomized Trial Comparing Low- vs High-Dose IV Dexamethasone for Patients With Moderate to Severe Migraine

BACKGROUND AND OBJECTIVES

Dexamethasone decreases the frequency of migraine recurrence after emergency department (ED) discharge. However, the optimal dose of dexamethasone is unknown. We hypothesized that dexamethasone 16 mg IV would allow greater rates of sustained headache relief than 4 mg when coadministered with metoclopramide 10 mg IV.

METHODS

This was a randomized double-blind study. Adults who presented with a headache meeting International Classification of Headache Disorders, 3rd edition, migraine criteria were eligible if they rated the headache as moderate or severe in intensity. Pain intensity was assessed for up to 2 hours in the ED and through telephone 48 hours and 7 days later. The primary outcome was sustained headache relief. Secondary outcomes included headache relief within 2 hours and the number of headache days during the subsequent week. Relying on a priori criteria, the data safety monitoring committee recommended halting the study early for futility.

RESULTS

A total of 1,823 patients were screened, and 209 patients were randomized. The mean age was 38 years (SD 11). One hundred seventy-nine of 209 (86%) identified as women. One hundred fifty-one of 209 (72%) of the population reported severe intensity; the rest reported moderate. Thirty-five of 102 (34%) participants in the metoclopramide +4 mg arm achieved sustained headache relief as did 42/102 (41%) participants in the metoclopramide +16 mg arm (absolute difference 7%, 95% CI -6% to 20%). Headache relief within 2 hours occurred in 77/104 (74%) low-dose and 82/105 (78%) high-dose participants (absolute difference 4%, 95% CI -8% to 16%). During the week after ED discharge, low-dose participants reported a median of 2 headache days (25th, 75th percentile 1, 5); in the high-dose arm, this was also 2 (25th, 75th percentile 0, 4) (mean difference 0.4, 95% CI -0.3 to 1.2).

DISCUSSION

When added to 10 mg IV metoclopramide, doses of dexamethasone greater than 4 mg are unlikely to benefit patients in the ED with migraine.

TRIAL REGISTRATION INFORMATION

This study was registered at ClinicalTrials.gov on October 2, 2019 (NCT04112823). The first patient was enrolled on December 22, 2019.

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that 16 mg of IV dexamethasone is unlikely to provide greater rates of sustained headache relief than 4 mg of IV dexamethasone among patients in the ED with migraine treated concurrently with IV metoclopramide.

Steroids in Headache: A Comprehensive Review of Recent Research

Background

Headache is an extremely common symptom of the general outpatient department and also the headache clinic, with prevalence of 48.9% in the general population. None has ever experienced headache in life time. Headache is seen in 1 patient out of 10 general practitioner (GP) consultations, 1 referral out of 3 is headache in neurology OPD, and 1 in 5 of all emergency medical admissions. Of all headaches, around 98% constitute primary headache: migraine without aura, tension headache, and cluster headache. With advancement in various drug modalities, certain headache forms respond less well to the regular approved medications, and some headaches are complicated by the analgesic itself. Steroids have been tried in many subtypes of headache, especially in primary forms of headache with dysautonomia, headache with trigeminal pathway activation and disinhibition, and in certain medication-culprit headaches. This subgroup of headaches is almost a challenge in an emergency for the headache expert as well. So, we need to assess the role of steroids in less well-responsive headaches.

Summary

Current reviewed evidence on the role of steroids in primary headache suggests that steroids have a role in status migrainosus and medication overuse headache when used in the mentioned and monitored manner. Consideration and further exploration of its role in other primary headaches may reveal insight into steroid efficacy as a treatment modality in various subtypes of headache.

Key message

Steroids, when used cautiously in specifically selected primary headaches under supervision, proved miraculous where other modalities failed.

Innate immune suppression by SARS-CoV-2 mRNA vaccinations: The role of G-quadruplexes, exosomes, and MicroRNAs

The mRNA SARS-CoV-2 vaccines were brought to market in response to the public health crises of Covid-19. The utilization of mRNA vaccines in the context of infectious disease has no precedent. The many alterations in the vaccine mRNA hide the mRNA from cellular defenses and promote a longer biological half-life and high production of spike protein. However, the immune response to the vaccine is very different from that to a SARS-CoV-2 infection. In this paper, we present evidence that vaccination induces a profound impairment in type I interferon signaling, which has diverse adverse consequences to human health. Immune cells that have taken up the vaccine nanoparticles release into circulation large numbers of exosomes containing spike protein along with critical microRNAs that induce a signaling response in recipient cells at distant sites. We also identify potential profound disturbances in regulatory control of protein synthesis and cancer surveillance. These disturbances potentially have a causal link to neurodegenerative disease, myocarditis, immune thrombocytopenia, Bell's palsy, liver disease, impaired adaptive immunity, impaired DNA damage response and tumorigenesis. We show evidence from the VAERS database supporting our hypothesis. We believe a comprehensive risk/benefit assessment of the mRNA vaccines questions them as positive contributors to public health.

Headache infusion centers: A survey on treatments provided, infusion center operations, and barriers to developing new infusion centers

BACKGROUND

Infusion therapy refers to the intravenous administration of medicines and fluids for the treatment of status migrainosus, severe persistent headaches, or chronic headache. Headache practices and centers offer this treatment for patients as an alternative to the emergency department (ED) setting. However, little information is available in the literature on understanding the operations of an infusion center.

OBJECTIVE

We sought to survey the Inpatient Headache & Emergency Medicine specialty section and the Academic Program Directors listserv of the American Headache Society (AHS) to better understand current practices.

METHODS

A survey was advertised and distributed to the listservs of both the Inpatient Headache & Emergency Medicine specialty section and the Academic Program Directors, which combined included both academic and private practices. In addition, the survey was available on laptops at related events at an annual AHS meeting in Scottsdale.

RESULTS

Of the 127 members of the combined group of both listservs, 50 responded with an overall survey response rate of 39%. Ten out of fifty were from programs with more than one responder completing the survey, leaving 40 unique headache programs. Academic programs made up the majority of programs (85%, 34/40). The total of 40 participating programs is comparable with the 47 academic headache programs listed on the American Migraine Foundation website at the time of the survey. Of the academic programs surveyed, most were hospital based (n = 23) compared with a satellite location (n = 11). Of all programs surveyed, 68% (27/40) offered infusion therapy. Of those that did not have an infusion practice (n = 13), the most common reason cited was insufficient staffing (n = 8). Key highlights of the survey included the following: The majority of programs offering infusions obtain prior authorization before scheduling (70%, 19/27) and offer patient availability 5 days/week (78%, 21/27) typically only during business hours (81%, 22/27). Programs reported that they typically give three to four medications during each infusion session (72%, 18/25). Treatment paradigms varied between programs. Programs surveyed were concentrated in the Northeast and Midwest regions of the United States.

CONCLUSION

The limited number of headache infusion centers overall may contribute to the limited ability of headache infusion centers to prevent ED migraine visits. Headache patients can have unpredictable headache onset, and most of the infusion practices surveyed appeared to adapt to this by offering infusions most days during a work week. However, this need for multiple days per week may also explain the most common reason for not having an infusion practice, which is insufficient staffing. Various treatment paradigms are implemented by different practitioners, and future studies will have to focus on investigation of best practice.

Chronic headaches and middle meningeal artery embolization

BACKGROUND

The middle meningeal artery (MMA) has been implicated in chronic headaches, but no studies have examined the relationship between MMA embolization and headaches.

METHODS

Patients treated with MMA embolization for a chronic subdural hematoma (cSDH) between January 1, 2018, and December 31, 2020, were retrospectively assessed. Patients with a Glasgow Coma Scale (GCS) score of 15 at discharge received a follow-up telephone call to assess their history of chronic headache, defined as a headache ≥2 years before the cSDH and symptoms ≥2 days/month. A Headache Impact Test (HIT-6) was performed during the follow-up telephone call. The primary outcome was resolution or improvement of headaches after embolization.

RESULTS

Of 76 patients undergoing MMA embolization for a cSDH during the study period, 56 (74%) had a discharge GCS score of 15. Of these 56 patients, 46 (82%) responded to a follow-up telephone call and were analyzed (mean [SD] age 68 [11] years; 36 [78%] men and 10 [22%] women). Nine (20%) reported chronic headaches before embolization. With a mean (SD) follow-up of 489 (173) days, eight of the nine patients reported improvement of chronic headaches, with seven having complete resolution. For these nine patients, the mean (SD) HIT-6 score was significantly higher before embolization than after embolization (64 [7.1] vs 40 [9.1], p<0.001).

CONCLUSION

In patients with chronic headaches who underwent MMA embolization for a cSDH, the majority reported improvement of headaches after the procedure. Future prospective studies are warranted to assess the usefulness of MMA embolization to treat chronic headaches.

Unveiling the comparative efficacy and tolerability of comprehensive treatments for migraine: A protocol of systematic review and Bayesian network meta-analysis

BACKGROUND

Migraine is a chronic paroxysmal incapacitating neurological disorder, which endangers the health of human worldwide ranking as the third most prevalent medical condition. There are no comprehensive estimates of treatments for migraine. We will conduct this systematic review and Bayesian network meta-analysis (NMA) to synthesis quantitative and comparative evidence on the efficacy and tolerability of all the known pharmacological and non-pharmacological interventions for migraine.

METHOD

We will perform the systematic electronic search of the literature utilizing MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing & Allied Health (CINAHL), and PsycINFO. We will only include randomized controlled trials (RCTs) of high quality which appraise the efficacy or safety of any potential pharmacological or non-pharmacological interventions in the treatment of patients with migraine. The traditional pairwise meta-analyses will be performed to anticipate the heterogeneities and publication bias and the NMA will be conducted within a Bayesian hierarchical model framework to obtain estimates for all valuable treatments for migraine. The entire heterogeneity will be quantified by Q statistic and I2 index. Other analyses included sensitivity analyses, meta-regression, and subgroup analyses will also be conducted. The whole process will be conducted using in R-3.6.0 software.

RESULTS

This study will obtain the efficacy and tolerability of all potential treatments for migraine, aiming at providing consolidated evidence to help make the best choice of interventions. The results will be published in a peer-reviewed journal.

DISCUSSION

This Bayesian network meta-analysis may be the first attempt to quantitatively synthesize the efficacy and tolerability of all potential treatments for migraine. And this method can ensure us to fully utilize both the direct and indirect evidence as well as gain the comparative estimates displayed in the derived hierarchies. Besides, we have registered this protocol on the international prospective register of systematic review (PROSPERO) (CRD42020157278).

Effectiveness of Emergency Department Treatment of Pediatric Headache and Relation to Rebound Headache

OBJECTIVE

This study aimed to assess the association between the degree of headache relief obtained in the pediatric emergency department (PED) with abortive treatment and unscheduled return visits to the PED for a recurrent or persistent headache within 72 hours.

METHODS

This was a retrospective observational study with 369 patients, all younger than 18 years, who presented to the PED with a primary complaint of either a headache or migraine. Patient and visit details were collected from the medical chart, along with presenting and discharge pain score. Percent pain reduction at discharge was determined through the following calculation: (Presenting Pain Score - Discharge Pain Score)/Presenting Pain Score. Associations were assessed using multivariable logistic regression.

RESULTS

No significant association was found between the percent pain reduction and return to the PED (P = 0.49). Mean presenting pain score at the index visit was statistically higher for those who ended up returning to the PED versus those who did not (8.1 vs 7.4; P = 0.02). A trend toward increase in return visits was seen among patients who had a headache duration greater than 3 days (odds ratio, 1.99) and patients who experienced less than 50% pain reduction in the PED (odds ratio, 1.77).

CONCLUSIONS

Complete resolution in the PED may not be necessary, given the lack of association between the degree of pain relief and revisit rates. Perhaps, the goal should be to achieve at least 50% pain reduction before discharge.

Investigating macrophage-mediated inflammation in migraine using ultrasmall superparamagnetic iron oxide-enhanced 3T magnetic resonance imaging

Background

Initiating mechanisms of migraine headache remain poorly understood and a biomarker of migraine does not exist. Inflammation pertaining to the wall of cerebral arteries and brain parenchyma has been suggested to play a role in migraine pathophysiology.

Objective

We conducted the first experimental human study to investigate macrophage-mediated inflammation as a possible biomarker of migraine.

Methods

Using ultrasmall superparamagnetic iron oxide (USPIO)-enhanced 3T magnetic resonance imaging (MRI), we investigated the presence of macrophages in cerebral artery walls and in brain parenchyma of patients with migraine without aura. We used the phosphodiesterase-3-inhibitor cilostazol as an experimental migraine trigger, and investigated both patients who received sumatriptan treatment, and patients who did not. To validate our use of USPIO-enhanced MRI, we included a preclinical mouse model with subcutaneous capsaicin injection in the trigeminal V1 area. The study is registered at ClinicalTrials.gov with the identifier NCT02549898.

Results

A total of 28 female patients with migraine without aura underwent a baseline MRI scan, ingested cilostazol, developed a migraine-like attack, and underwent an USPIO-enhanced MRI scan > 24 hours after intravenous administration of USPIO. Twelve patients treated their attack with 6 mg s.c. sumatriptan, while the remaining 16 patients received no migraine-specific rescue medication. The preclinical model confirmed that USPIO-enhanced MRI detects macrophage-mediated inflammation. In patients, however, migraine attacks were not associated with increased USPIO signal on the pain side of the head compared to the non-pain side.

Conclusion

Our findings suggest that migraine without aura is not associated with macrophage-mediated inflammation specific to the head pain side.

Oral dexamethasone for the prevention of acute migraine recurrence in pediatric patients presenting to the emergency department with migraine

Objective:

To assess the feasibility of a randomized controlled trial protocol that aims to determine the efficacy and safety of oral dexamethasone compared to placebo for the prevention of migraine recurrence in children and adolescents visiting the pediatric emergency department (ED) with migraine.

Methods:

This study was a two-arm, parallel-group, randomized, placebo-controlled, double-blind pilot trial of patients presenting to the pediatric ED with migraine. Eligible participants were randomized at 1:1 ratio to receive either oral dexamethasone 0.6 mg/kg (maximum 15 mg) or matched placebo as a single dose. Efficacy and safety outcomes were assessed at discharge, 48 h and 7 days after discharge. The primary outcome of the trial was feasibility and was assessed through participant recruitment rate, follow-up completion rates, participant satisfaction ratings and comparison of enrolled versus non-enrolled participants. Efficacy and safety outcomes were not analyzed given that this was a pilot study.

Results:

Twelve participants were enrolled over the 6-month recruitment period. This represents 60% of the planned sample size and a 10.5% recruitment rate. No other feasibility issues were identified and patients expressed high satisfaction rates with their treatment: 90.9% were satisfied with their treatment at discharge and at 48-h follow-up and 81.8% were satisfied with their treatment at 7-day follow-up (81.8%). There were no significant differences observed when comparing enrolled participants to those not enrolled.

Conclusion:

This pilot randomized controlled trial is the first to assess dexamethasone in the pediatric ED for the prevention of migraine recurrence. The protocol is feasible but recruitment in a single center was lower than expected. Future pediatric ED migraine studies may use innovative or pragmatic trial designs to maximize feasibility from a recruitment standpoint.

Methylprednisolone blocks interleukin 1 beta induced calcitonin gene related peptide release in trigeminal ganglia cells

Background

Methylprednisolone (MPD) is a rapid acting highly effective cluster headache preventive and also suppresses the recurrence of migraine attacks. Previously, we could demonstrate that elevated CGRP plasma levels in a cluster headache bout are normalized after a course of high dose corticosteroids. Here we assess whether MPD suppresses interleukin-1β (IL-1β)- and prostaglandin E₂ (PGE₂)-induced CGRP release in a cell culture model of trigeminal ganglia cells, which could account for the preventive effect in migraine and cluster headache. Metoprolol(MTP), a migraine preventive with a slow onset of action, was used for comparison.

Methods

Primary cultures of rat trigeminal ganglia were stimulated for 24 h with 10 ng/ml IL-1β or for 4 h with 10 μM PGE₂ following the exposure to 10 or 100 μM MPD or 100 nM or 10 µM MTP for 45 min or 24 h. CGRP was determined by using a commercial enzyme immunoassay.

Results

MPD but not MTP blocked IL-1β-induced CGRP release from cultured trigeminal cells. PGE₂-stimulated CGRP release from trigeminal ganglia cell culture was not affected by pre-stimulation whether with MPD or MTP.

Conclusion

MPD but not MTP suppresses cytokine (IL-1β)-induced CGRP release from trigeminal ganglia cells. We propose that blockade of cytokine mediated trigeminal activation may represent a potential mechanism of action that mediates the preventive effect of MTP on cluster headache and recurrent migraine attacks.

Using standardized patients to evaluate medical students' evidence-based medicine skills

OBJECTIVES

To analyze the effectiveness of an Evidence Based Medicine Objective Structured Clinical Examination (EBM OSCE) with standardized patients for end of third year medical students at our institution.

METHODS

This was a single-center prospective cross-sectional investigation. As part of the eight-station OSCE exam, the authors developed and implemented a new 25-minute EBM OSCE station with the goal of evaluating evidence based medicine skills necessary for daily clinical encounters. The OSCE case involved a highly educated patient with a history of recurrent debilitating migraines who has brought eight specific questions regarding the use of steroids for migraine headaches. Students were provided computer stations equipped to record a log of the searches performed.

RESULTS

One hundred and four third-year medical students participated in this study. The average number of search tools used by the students was 4 (SD = 2). The 104 students performed a total of 896 searches. The two most commonly used websites were uptodate.com and google.com. Sixty-nine percent (95% CI, 60% to 78%) of students were able to find a meta-analysis regarding the use of dexamethasone for the prevention of rebound migraines. Fifty-two percent of students were able to explain that patients who took dexamethasone had a moderate RR (0.68 to 0.78) of having a recurrent migraine, and 71% of students were able to explain to the standardized patient that the NNT for dexamethasone was nine.

CONCLUSION

The EBM OSCE was successfully integrated into the existing eight-station OSCE and was able to assess student EBM skills.

Asthma is a risk factor for new onset chronic migraine: Results from the American migraine prevalence and prevention study

OBJECTIVES

To test the hypothesis that in persons with episodic migraine (EM), asthma is a risk factor for the onset of chronic migraine (CM).

BACKGROUND

Migraine and asthma are comorbid chronic disorders with episodic attacks thought to involve inflammatory and neurological mechanisms. Herein, we assess the influence of asthma on the clinical course of EM.

METHODS

To be eligible for this observational cohort study, AMPP Study participants had to meet criteria for EM in 2008, complete the validated six-item asthma questionnaire from the European Community Respiratory Health Survey (ECRHS) in 2008, and provide follow-up data in 2009. Using the ECRHS, we defined asthma as a binary variable (present or absent) based on an empirical cut score and developed a Respiratory Symptom Severity Score (RSSS) based on the number of positive responses (no severity = 0 positive responses, low severity = 1-2 positive responses, moderate severity = 3-4 positive responses, high severity = 5-6 positive responses). Chronic migraine was the primary outcome measure and was defined as those with ≥15 headache days per month on the 2009 AMPP Study survey. We used logistic regression in separate models to assess the influence of asthma as a binary variable (Model 1) and RSSS score categories (Model 2 using no respiratory symptoms as the reference) on CM onset after adjusting for sociodemographic factors, headache day frequency, migraine preventive medication use, and medication overuse.

RESULTS

The eligible sample for this study included 4446 individuals with EM in 2008 of whom 17% had asthma. This group had a mean age of 50.4 and was 80.8% female. In 2009, new onset CM developed in 2.9% (131/4446) of the 2008 EM cohort, including 5.4% (40/746) of the asthma subgroup and 2.5% (91/3700) of the non-asthma subgroup. In comparison to those without asthma, the adjusted odds for individuals with asthma and EM in 2008 to develop CM in 2009 were greater than two (adjusted odds ratio [aOR] 2.1; 95% CI: 1.4-3.1). Using the RSSS, the aOR for CM onset increased with the number of asthma symptoms, but only those in the high RSSS category showed a statistically significant increase in the odds of chronic migraine onset in comparison with the no RSSS reference group (aOR 3.3; 95% CI 1.7-6.2).

CONCLUSIONS

Asthma is associated with an increased risk of new onset CM 1 year later among individuals with EM, with the highest risk being among those with the greatest number of respiratory symptoms. The exact mechanisms underlying this association are unknown, but could suggest mast cell degranulation, autonomic dysfunction, or shared genetic or environmental factors.

What is the evidence for the use of corticosteroids in migraine?

Corticosteroids are widely prescribed for the management of migraine attacks. The earliest clinical studies examining the efficacy of corticosteroid monotherapy for managing migraine attacks date back to 1952. Since then, 26 heterogeneous clinical studies and four meta-analyses have been conducted to assess the efficacy of corticosteroids in either aborting acute migraine attacks, prolonged migraine attacks or recurrent headaches. Most of these (86 %) studies employed different comparator arms with corticosteroids monotherapy administration while some studies (14 %) evaluated adjunctive corticosteroid therapy. The majority of these clinical studies revealed the superior efficacy of corticosteroids as mono- or adjunctive-therapy both for recurrent and acute migraine attacks, while the remaining showed non-inferior efficacy. Different forms of oral and parenteral corticosteroids in either single-dose or short-tapering schedules are prescribed; there are clinical studies supporting the efficacy of both methods. Corticosteroids can be administered safely up to six times annually. Corticosteroids are also useful in managing patients who frequent emergency departments with "medication-seeking behavior." Migraine patients with refractory headaches, history of recurrent headaches, severe baseline disability, and status migrainosus were found to have the most beneficial response from corticosteroid therapy.

The place of corticosteroids in migraine attack management: A 65-year systematic review with pooled analysis and critical appraisal

BACKGROUND AND OBJECTIVES

Headaches recur in up to 87% of migraine patients visiting the emergency department (ED), making ED recidivism a management challenge. We aimed herein to determine the role of corticosteroids in the acute management of migraine in the ED and outpatient care.

METHODS

Advanced search strategies employing PubMed/MEDLINE, Web of Science, and Cochrane Library databases inclusive of a relevant gray literature search was employed for Clinical Studies and Systematic Reviews by combining the terms "migraine" and "corticosteroids" spanning all previous years since the production of synthetic corticosteroids ca. 1950 until August 30, 2014. Methods were in accordance with MOOSE guidelines.

RESULTS

Twenty-five studies (n = 3989, median age 37.5 years, interquartile range or IQR 35-41 years; median male:female ratio 1:4.23, IQR 1:2.1-6.14; 52% ED-based, 56% randomized-controlled) and four systematic reviews were included. International Classification of Headache Disorders criteria were applied in 64%. Nineteen studies (76%) indicated observed outcome differences favoring benefits of corticosteroids, while six (24%) studies indicated non-inferior outcomes for corticosteroids. Median absolute risk reduction was 30% (range 6%-48.2%), and 11% (6%-48.6%) for 24-, and 72-hour headache recurrence, respectively. Parenteral dexamethasone was the most commonly (56%) administered steroid, at a median single dose of 10 mg (range 4-24 mg). All meta-analyses revealed efficacy of adjuvant corticosteroids to various abortive medications-indicating generalizability. Adverse effects were tolerable. Higher disability, status migrainosus, incomplete pain relief, and previous history of headache recurrence predicted outcome favorability.

CONCLUSIONS

Our literature review suggests that with corticosteroid treatment, recurrent headaches become milder than pretreated headaches and later respond to nonsteroidal therapy. Single-dose intravenous dexamethasone is a reasonable option for managing resistant, severe, or prolonged migraine attacks.