Abstract
Background. Dexamethasone decreases the frequency of migraine recurrence after emergency department (ED) discharge. However, the optimal dose of dexamethasone is unknown. We hypothesized that dexamethasone 16mg IV would allow greater rates of sustained headache relief than 4mg when co-administered with metoclopramide 10mg IV.
Methods. This was a randomized double-blind study. Adults who presented with a headache meeting ICHD3 migraine criteria were eligible if they rated the headache as moderate or severe in intensity. Pain intensity was assessed for up to two hours in the ED and by telephone 48 hours and 7 days later. The primary outcome was sustained headache relief. Secondary outcomes included headache relief within two hours and 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. 1823 patients were screened and 209 were randomized. The mean age was 38 years (SD- 11). 179/209 (86%) identified as women. 151/209 (72%) of the population reported severe intensity; the rest reported moderate. 35/102 (34%) participants in the metoclopramide +4mg arm achieved sustained headache relief as did 42/102 (41%) of participants in the metoclopramide +16mg arm (95%CI for absolute difference of 7%: -6, 20%). Headache relief within two hours occurred in 77/104 (74%) low dose and 82/ 105 (78%) high dose participants (95%CI for absolute difference of 4% = -8, 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) (95%CI for mean difference of 0.4: -0.3, 1.2).
Conclusions. When added to 10mg IV metoclopramide, doses of dexamethasone greater than 4mg are unlikely to benefit patients in the ED with migraine.
Trial registration information. This study was registered at clinicaltrials.govon Oct 2, 2019 (NCT04112823). The first patient was enrolled Dec 22, 2019.
Classification of evidence. This study provides Class 1 evidence that 16mg of IV dexamethasone is unlikely to provide greater rates of sustained headache relief than 4mg of IV dexamethasone among patients in the ED with migraine treated concurrently with IV metoclopramide.
- Received January 17, 2023.
- Accepted in final form May 31, 2023.
- Copyright © 2023 American Academy of Neurology. Unauthorized reproduction of this article is prohibited
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