Hostname: page-component-7c8c6479df-p566r Total loading time: 0 Render date: 2024-03-19T10:23:21.727Z Has data issue: false hasContentIssue false

Intravenous dexamethasone to prevent the recurrence of benign headache after discharge from the emergency department: a randomized, double-blind, placebo-controlled clinical trial

Published online by Cambridge University Press:  21 May 2015

Eric Y. Baden*
Affiliation:
Brooke Army Medical Center and Wilford Hall Medical Center, San Antonio, Texas Emergency Medicine Resident, San Antonio Uniformed Services Health Education Consortium (SAUSHEC), San Antonio, Texas
Curtis J. Hunter
Affiliation:
Brooke Army Medical Center and Wilford Hall Medical Center, San Antonio, Texas Emergency Medicine Faculty, Brooke Army Medical Center, San Antonio, Texas
*
Brooke Army Medical Center, Department of Emergency Medicine, 3851 Roger Brooke Dr., Fort Sam Houston TX 78234-6200; 210 916-1006

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Objective:

To evaluate whether the addition of intravenous (IV) dexamethasone to standard emergency department (ED) benign headache therapy would reduce the incidence of headache recurrence at 48–72 hours.

Methods:

This randomized, double-blind, placebo-controlled clinical trial of adult patients presenting with the chief complaint of headache was conducted in the ED of 2 academic, urban Level 1 hospitals. Headache evaluation and therapy were determined by the treating physician, and, before discharge, patients were administered either 10 mg of IV dexamethasone or placebo. The treatment groups had similar baseline characteristics, abortive therapy, IV fluids and degree of pain relief achieved before discharge. Patients were contacted 48–72 hours following discharge and asked whether their headache was “better,” “worse” or “remained unchanged” when compared with their symptoms at discharge. Those whose headaches were “worse” or “unchanged,” and those who reported a return of headache after being pain free at discharge were considered to be treatment failures and classified as having had a recurrence. The patient's headache at follow-up was further categorized as severe (i.e., provoking another physician visit or interfering with daily activity) or mild (i.e., requiring self-medication or no treatment).

Results:

Fifty-seven patients met the inclusion criteria and 2 were lost to follow-up, leaving 55 for analysis. At follow-up, 9.7% (3/31) of those receiving dexamethasone had headache recurrence, versus 58.3% (14/24) of those receiving placebo (p < 0.001). Four dexamethasone recipients (12.9%) had severe headaches at follow-up compared with 8 (33.3%) in the placebo group (p = 0.14).

Conclusions:

In this study, IV dexamethasone reduced headache recurrence at 48–72-hour follow-up. Given its excellent safety profile and likely benefit, IV dexamethasone should be considered for ED headache patients after standard evaluation and therapy.

Type
Original Research • Recherche originale
Copyright
Copyright © Canadian Association of Emergency Physicians 2006

References

1.Henry, GL. Headache. In: Marx, JA, editor. Rosen’s emergency medicine: concepts and clinical practice. 5th ed. St. Louis: Mosby, Inc.; 2002. p. 149–53.Google Scholar
2.McCaig, LF. National Hospital Ambulatory Medical Care Survey: 1998 emergency department summary. No 313, May 2000. Hyattsville (MD): National Center for Health Statistics. Available: hhtp://www.cdc.gov/nchs/data/ad/ad313.pdf (accessed 2006 Oct 6).Google Scholar
3.Olesen, J. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988;8 (suppl 7):196.Google Scholar
4.Saper, JR. Chronic headache syndromes. Neurol Clin 1989;7:387411.Google Scholar
5.Fogarty, JP. Headache. In: Sloane, PD. Essential of family medicine. 3rd ed. Baltimore: Williams and Wilkins; 1998. p. 447–53.Google Scholar
6.Marcus, DA. Migraine and tension-type headaches: the questionable validity of current classification systems [review]. Clin J Pain 1992;8(1):2836; discussion 37–8.CrossRefGoogle ScholarPubMed
7.Jones, J. Intravenous prochlorperazine for acute headache [letter]. JAMA 1989;262:502.Google Scholar
8.Thomas, SH. Emergency department treatment of migraine, tension, and mixed-type headache. JEM 1994;12:657–64.Google Scholar
9.Ducharme, J, Beveridge, RC, Lee, JS, et al. Emergency management of migraine: Is the headache really over? Acad Emerg Med 1998;5:899905.Google Scholar
10.Neighbor, ML. Sumatriptan: a new treatment for migraine. West J Med 1993;159:597–8.Google ScholarPubMed
11.Bateman, DN. Sumatriptan. Lancet 1993;341:221–3.Google Scholar
12.Dahlof, C, Ekbom, K, Persson, L. Clinical experiences from Sweden on the use of subcutaneously administered sumatriptan in migraine and cluster Headache. Arch Neurol 1994;51:1256–61.CrossRefGoogle ScholarPubMed
13.Cameron, JD, Lane, PL, Speechley, M. Intravenous chlorpro-mazine vs. intravenous metoclopramide in acute migraine headache. Acad Emerg Med 1995;2:597602.CrossRefGoogle ScholarPubMed
14.Larkin, GL, Prescott, JE. A randomized, double-blind, comparative study of the efficacy of ketorolac versus meperidine in the treatment of severe migraine. Ann Emerg Med 1992;21:919–24.CrossRefGoogle ScholarPubMed
15.Innes, GD, Macphail, I, Dillon, EC, et al. Dexamethasone prevents relapse after emergency department treatment of acute migraine: a randomized clinical trial. Can J Emerg Med 1999;1(1):2633.CrossRefGoogle ScholarPubMed
16.Jones, JS, Brown, MD, Bermingham, M, et al. Efficacy of par-enteral dexamethasone to prevent relapse after emergency department treatment of acute migraine. Acad Emerg Med 2003;10:542.CrossRefGoogle Scholar
17.Moskovitz, MA. Neurogenic inflammation in the pathophysiol-ogy and treatment of migraine. Neurology 1993;43(suppl 3):S16-20.Google Scholar
18.Buzzi, MG, Moskowitz, MA. Evidence for 5-HT1B/1D receptors mediating the antimigraine effect of sumatriptan and dihydroer-gotamine. Cephalalgia 1991;11:165–8.CrossRefGoogle Scholar
19.Lance, JW. Current concepts of migraine pathogenesis. Neurology 1993;43(suppl 3):S11-5.Google ScholarPubMed
20.Goadsby, PJ, Gundlach, AL. Localization of 3H-dihydroergota-mine-binding sites in the cat central nervous system: relevance to migraine. Ann Neurol 1991;29:91–4.Google Scholar
21.Hardman, JG, et al, editors. Goodman & Gilman’s The pharmacological basis of therapeutics. New York: McGraw-Hill; 1996.Google Scholar
22.Gallagher, RM. Emergency treatment of intractable migraine. Headache 1986;26:74–5.CrossRefGoogle ScholarPubMed
23.Klapper, J, et al. The emergency treatment of acute migraine headache: a comparison of intravenous dihydroergotamine, dex-amethasone, and placebo. Cephalalgia 1991;11:159–60.CrossRefGoogle Scholar
24.Saadah, HA. Abortive migraine therapy in the office with dex-amethasone and prochlorperazine. Headache 1994;34:366–70.CrossRefGoogle Scholar
25.Friedman, BW, principal investigator. Headache in the emergency department (ED) — A multi-center research network to optimize the ED treatment of migraines [Internet]. July 2005. Available: http://www.clinicaltrials.gov/ct/show/NCT00122278 (accessed 2006 Oct 6).Google Scholar
26.Bell, R, Montoya, D, Shuaib, A, et al. A comparative trial of three agents in the treatment of acute migraine headache. Ann Emerg Med 1990;19:1079–82.CrossRefGoogle ScholarPubMed
27.Stiell, IG, Dufour, DG, Moher, D, et al. Methotrimeprazine versus meperidine and dimenhydrinate in the treatment of severe migraine: a randomized, controlled trial. Ann Emerg Med 1991;20:1201–5.CrossRefGoogle ScholarPubMed
28.Larkin, GL, Prescott, JE. A randomized, double-blind, comparative study of the efficacy of ketorolac versus meperidine in the treatment of severe migraine. Ann Emerg Med 1992;21:919–24.Google Scholar
29.Fusco, M, D’Andrea, G, Micciche, F, et al. Neurogenic inflammation in primary headaches. Neurol Sci 2003;24(suppl 2):S61-4.CrossRefGoogle ScholarPubMed
30.Peroutka, SJ. Neurogenic inflammation and migraine: implications for the therapeutics. Mol Interv 2005;5:304–11.CrossRefGoogle ScholarPubMed
31.MDConsult [Internet]. Sept 2002. Available to members only at: http://home.mdconsult.com/das/drug/view/22701981Google Scholar
32.Thomas, MC, Costello, SA. Disseminated strongyloidiasis arising from a single dose of dexamethasone before stereotactic radiosurgery. Case report. Int J Clin Pract 1998;52:520–1.Google Scholar
33.Peto, R, Pike, MC, Armitage, P, et al. Design and analysis of randomized clinical trials requiring prolonged observation of each patient I. Introduction and design. Br J Cancer 1976;34:585612.CrossRefGoogle ScholarPubMed
34.Hulot, JS, Cucherat, M, Charlesworth, A, et al. Planning and monitoring of placebo-controlled survival trials: comparison of the triangular test with usual interim analyses methods. Br J Clin Pharmacol 2003;55:299306.Google Scholar
35.Rittichier, KK, Ledwith, CA. Outpatient treatment of moderate croup with dexamethasone: Intramuscular versus oral dosing. Pediatrics 2000;106:1344–8.Google Scholar