Department of Emergency Medicine, Bronx, NY; Montefiore Health, Bronx, NY.
Department of Emergency Medicine, Bronx, NY; Montefiore Health, Bronx, NY.
Ann Emerg Med. 2019 Feb;73(2):141-149. doi: 10.1016/j.annemergmed.2018.09.028. Epub 2018 Nov 16.
Migraine patients continue to report headache during the days and weeks after emergency department (ED) discharge. Dexamethasone is an evidence-based treatment of acute migraine that decreases the frequency of moderate or severe headache within 72 hours of ED discharge. We hypothesize that intramuscular methylprednisolone acetate, a long-acting steroid that remains biologically active for 14 days, will decrease the number of days with headache during the week after ED discharge by at least 1 day compared with intramuscular dexamethasone.
We conducted a randomized, blinded clinical trial comparing intravenous metoclopramide at 10 mg+intramuscular dexamethasone at 10 mg with intravenous metoclopramide at 10 mg+intramuscular methylprednisolone acetate at a dose of 160 mg for patients presenting to 2 different EDs with moderate or severe migraine. Outcomes were assessed by telephone with a standardized instrument. The primary outcome was number of days with headache during the week after ED discharge. Secondary outcomes were complete freedom from headache, without the necessity of additional headache medication for the entire week after ED discharge, and medication preference, as determined by asking the patient whether he or she would want to receive the same medication again.
One hundred nine patients received dexamethasone and 111 received methylprednisolone acetate. We obtained primary outcome data from 101 dexamethasone patients and 106 methylprednisolone acetate patients. Dexamethasone patients reported 3.0 headache days and methylprednisolone acetate 3.3 headache days (95% confidence interval for rounded mean difference of 0.4 days: -0.4 to 1.1). Of 107 dexamethasone patients with analyzable data, 10 (9%) reported complete freedom from headache at 1 week versus 6 of 110 (5%) methylprednisolone acetate patients (95% confidence interval for difference of 4%: -3% to 11%). In the dexamethasone group, 76 of 101 (75%) patients would want the same medication again versus 75 of 106 (71%) of methylprednisolone acetate patients (95% confidence interval for difference of 4%: -8% to 17%). Other than injection site reactions, which were more common in the methylprednisolone acetate group, there were no substantial differences in frequency of adverse events.
Methylprednisolone acetate does not decrease the frequency of post-ED discharge headache days compared with dexamethasone. Most migraine patients are likely to continue to experience headache during the week after ED discharge.
急诊（ED）出院后数天至数周，偏头痛患者仍有头痛报告。地塞米松是一种治疗急性偏头痛的循证药物，可在 ED 出院后 72 小时内降低中重度头痛的发生频率。我们假设肌肉注射长效类固醇醋酸甲泼尼龙，其生物活性可维持 14 天，与肌肉注射地塞米松相比，将至少减少 ED 出院后一周内头痛天数 1 天。
我们开展了一项随机、双盲临床试验，比较静脉注射甲氧氯普胺 10mg+肌肉注射地塞米松 10mg 与静脉注射甲氧氯普胺 10mg+肌肉注射醋酸甲泼尼龙 160mg 治疗 2 家不同 ED 中度或重度偏头痛患者的效果。采用标准化工具通过电话进行结局评估。主要结局为 ED 出院后一周内头痛天数。次要结局包括完全无头痛，整个 ED 出院后一周无需使用其他头痛药物，以及药物偏好，通过询问患者是否希望再次接受相同药物来确定。
109 例患者接受地塞米松治疗，111 例患者接受醋酸甲泼尼龙治疗。101 例地塞米松患者和 106 例醋酸甲泼尼龙患者获得了主要结局数据。地塞米松患者报告头痛 3.0 天，醋酸甲泼尼龙患者头痛 3.3 天（四舍五入均值差 0.4 天的 95%置信区间：-0.4 至 1.1）。107 例可分析数据的地塞米松患者中，10 例（9%）报告 1 周时完全无头痛，110 例醋酸甲泼尼龙患者中 6 例（5%）（95%置信区间差值为 4%：-3%至 11%）。地塞米松组中，101 例患者中有 76 例（75%）希望再次使用相同药物，而醋酸甲泼尼龙组中有 106 例患者中有 75 例（71%）（95%置信区间差值为 4%：-8%至 17%）。除注射部位反应外，醋酸甲泼尼龙组更常见，其他不良事件的发生频率无实质性差异。
与地塞米松相比，醋酸甲泼尼龙并未降低 ED 出院后头痛天数。大多数偏头痛患者在 ED 出院后一周内仍可能继续头痛。
