Pearls of Wisdom: Recurring Migraine

Sylvia is a 32-year-old woman with an almost 20-year history of classic migraine who presents in your Urgent Care clinic. She is traveling with her husband and 2 young children, and has another 7 hours of driving ahead of her. Despite generally successful prophylaxis of her migraine with a beta blocker, she is having a breakthrough migraine headache.

She reports that she has previously responded very well to parenteral sumatriptan, with headache resolution within 2 hours. However, 2 years prior during a similar traveling experience, her headache recurred about 12 hours later and required an additional emergency room visit.

Is there anything that works better?   

A. Oxycodone.
B. Lorazepam.
C. Dexamethasone.
D. Human chorionic gonadotropin.

What advice would you give?
(Answer and discussion on next page)
 

Louis Kuritzky. MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. His “Pearls of Wisdom” as we like to call them, have been shared with primary care physicians annually in an educational presentation entitled 5TIWIKLY (“5 Things I Wish I Knew Last Year”…. or the grammatically correct, “5 Things I Wish I’d Known Last Year”).

Now, for the first time, Dr Kuritzky is sharing with the Consultant360 audience. Sign up today to receive new advice each week.

Answer: Dexamethasone

The literature suggests that migraneurs are often dissatisfied customers, either because of lack of relief for their headache or lack of validation by the clinician of the burden of their illness. Were migraine to simply occupy a few minutes per month with annoying headache, perhaps the problem would be rightly relegated to the “nuisance” category. But, to the contrary, many patients with migraine describe a sequence of events that is both large in scope of time and dysfunction.
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A Timeline

First, there may be a prodrome to migraine that lasts as long as an entire day—during which the migraneur reports feeling “not quite right.” A similar phenomenon has been reported by some seizure sufferers, who say that in the day prior to a seizure, they note a neurologic change that they learn to appreciate heralds the arrival of a seizure.

After a day-long prodromal state, the migraneur may progress (as in the case of our patient, Sylvia) to the stage of aura. Aura may be disabling due to direct impairment of critical functions. For instance, the most common migraine aura is visual field alteration, during which the migraneur may be unable to safely drive or perform reading tasks.

After aura, a headache—which is typically described as disabling—occurs. Indeed, even when the headache is not disabling, it may lead to important impairment of function. My first encounter with the word presenteeism (as opposed to absenteeism) occurred in reference to migraine headache—the sufferer may not necessarily be absent from work, but may not be able to provide useful service at work, hence presenteeism.

After the headache, the migraneur may enter a phase of postdrome, during which s/he may again report a “washed out” or “just not feeling myself” condition, and these ill-defined symptoms may persist for as long as a day or longer. From this description, one can readily see that migraine may be much more than just a few minutes of nuisance headache; rather, it may produce a burdensome disability.

Why Dexamethasone?²

Our Case

Sylvia’s situation is not atypical. In one review of migraneurs seen in emergency departments, almost half experienced recurrent headache within the ensuing 24 hours, despite appropriate and effective acute headache resolution.¹ We would like to be able to provide not only immediate relief, but sustained relief.

Many clinical trials of pharmacotherapeutic agents for migraine do not extend far beyond the initial headache episode. Indeed, the percent of patients who are pain-free at the 2-hour mark is a commonly employed comparative metric in migraine trials.

Dexamethasone: Convinced?²

So Sylvia’s request for “something better” incorporates her desire to avoid headache recurrence. Fortunately, clinical trials have confirmed that the addition of parenteral dexamethasone to traditional abortive therapy provides a meaningful reduction in rate of headache recurrence. Individual trials and metaanalysis are convincing that even though the addition of dexamethasone to abortive regimens does not provide additional immediate pain relief, it does meaningfully reduce recurrences.²

What’s the “Take Home”?

The consequences of migraine range from mild to severe. Recurrent migraine headache is an oft-overlooked problem despite initial successful treatment to abort migraine. Dexamethasone has been confirmed to reduce risk of recurrent migraine and provides a safe and generally well-tolerated method to avoid the need for recurrent acute care visits.

References:

1. Duchame J, Beveridge RC, Lee JS, Beaulieu S. Emergency management of migraine: Is the headache really over? Acad Emerg Med. 1998;5:899-905.
2. Colman I, Friedman BW, Brown MD, et al. Parenteral dexamethoasone for acute severe migraine headache. BMJ. 2008;336:1359-1361.