Higher dose of Dexamethasone with metoclopramide may not provide additional relief to migraine patients in ED

USA: A dose of dexamethasone greater than 4mg when added to 10mg IV metoclopramide is unlikely to benefit patients in the emergency department (ED) with migraine, a recent study published in Neurology has shown. 

Dexamethasone is a common steroid that is often used for migraine treatment in the EDs. The study by Benjamin W. Friedman and colleagues suggested that the dose of dexamethasone may not significantly impact the rate of sustained headache relief when co-administered with metoclopramide.

Key findings from the study include:

• The study was a randomized, double-blind trial that included adults with migraines meeting the International Classification of Headache Disorders (ICHD3) criteria. The participants rated their headache intensity as moderate or severe. Neurology
• A total of 209 participants were randomized into two groups: one received dexamethasone 4 mg intravenously along with metoclopramide 10mg IV, and the other received dexamethasone 16 mg IV along with metoclopramide 10mg IV.
• The primary outcome was sustained headache relief, while secondary outcomes included headache relief within two hours and the number of headache days during the following week.
• The results showed that the rate of sustained headache relief was 34% in the low-dose group (4mg dexamethasone) and 41% in the high-dose group (16 mg dexamethasone). However, the difference was not statistically significant.
• Headache relief within two hours occurred in 74% of the low-dose group and 78% of the high-dose group, with no significant difference.
• Both groups reported a median of 2 headache days during the week after ED discharge, with no significant difference in headache frequency.

In summary, the study indicates that when combined with 10mg IV metoclopramide, doses of dexamethasone greater than 4 mg are unlikely to provide additional benefits for patients with migraines in the ED. The findings suggest that a higher dose of dexamethasone does not significantly impact sustained headache relief, headache relief within two hours, or the number of headache days in the week following ED discharge.

Reference:

Friedman, B. W., Solorzano, C., Kessler, B. D., Martorello, K., Lutz, C. L., Feliciano, C., Adler, N., Moss, H., Cain, D., & Irizarry, E. (2023). Randomized trial comparing low- vs high-dose IV dexamethasone for patients with moderate to severe migraine. Neurology, 10.1212/WNL.0000000000207648. https://doi.org/10.1212/wnl.0000000000207648