Dexamethasone decreases migraine recurrence observed after treatment with a triptan combined with a nonsteroidal anti-inflammatory drug

Abstract

-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 (≥ 60%, mean recurrence rate 74,8%) with the single use of sumatritpan 100mg or zolmitriptan 2,5mg 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 200mg or rofecoxib 25mg 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 4mg 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 4mg 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. KEY WORDS: migraine recurrence, dexamethasone, triptans, nonsteroidal anti-inflammatory drugs.Dexametasona diminui a recorrência de migrânea observada após tratamento com um triptano e um antinflamatório não esteroide RESUMO Tema e objetivos: Triptanos são drogas eficientes para o tratamento agudo da migrânea. Entretanto, cerca de 30 a 40% dos pacientes tratados, comumente apresentam recorrência antes de 24 horas e consequentemente necessitam de uma nova dose. A associação de antinflamatórios não esteroides (AINE) como o ácido tolfenâmico e o naproxeno sódico demonstraram eficácia na redução da recorrência observada com o uso isolado do sum...

Does the Addition of Dexamethasone to Standard Therapy for Acute Migraine Headache Decrease the Incidence of Recurrent Headache for Patients Treated in the Emergency Department? A Meta‐analysis and Systematic Review of the Literature

“…11,12,[14][15][16][17][18] In 1986, Gallagher 20 published the first clinical trial with a control arm that supported the use of dexamethasone in the ED. In this trial of 130 patients, those receiving adjunctive dexamethasone therapy had a significantly lower rate of moderate or severe headache at 24 hours compared to the control group (28% vs. 71%, p < 0.05).…”

“…9,10 Uncontrolled clinical trials have shown that, in both the inpatient setting and the outpatient clinic setting, dexamethasone is highly effective in reducing the severity of migraine headache and the rate of headache recurrence. [11][12][13][14][15][16][17][18][19] Although initial controlled clinical trials demonstrated the same high-level of efficacy, [20][21][22][23][24][25][26] the results of several recent ED-based trials have questioned the utility of dexamethasone for this purpose. [27][28][29][30][31][32][33][34][35][36][37][38][39][40] The goals of this systematic review were to critically appraise the existing literature and to provide recommendations for patient care regarding the use of dexamethasone for the prevention of headache relapse in patients with acute migraine headache in the ED.…”

Migraine in the triptan era: progresses achieved, lessons learned and future developments

“…In selected patients, triptans may be associated to other medications, in order to address specific issues, such as incomplete relieve, recurrence, or slow onset of action [71][72][73] .…”

What’s new in the treatment of acute migraine

“…The proposal of also using dexamethasone in a limited population of migraineurs still presenting with headache recurrence after combined treatment of a triptan with an NSAID, such as naproxen sodium or tolfenamic acid, should be considered with caution. The usefulness of this approach needs to be confirmed, as in previous clinical experiences, by case-control studies and studies with a randomized double-blind design [11]. With the affinity of triptans for 5-HT1F receptors, it is hypothetically possible that they could be a further potential target in acute migraine.…”