Methodology: 3.5/5
Usefulness: 4/5

Friedman BW, et al. Neurology. 2023 Oct 3;101(14):e1448-e1454. 

Question and Methods: This double-blinded RCT of 209 patients presenting to the ED with moderate to severe migraines compared high- to low- dose dexamethasone (16 mg vs 4 mg) on sustained headache relief 48 hours post discharge.  
Findings: There was no significant difference in sustained headache relief between the high- (41%) and low- (34%) dose dexamethasone groups when co-administered with metoclopramide (absolute difference 7%, 95% CI -6% to 20%). 
Limitations: The major limitation of this study is generalizability to patients receiving alternative abortive treatments in the ED in addition to early discontinuation of the study which may blunt the true magnitude of absolute difference.  

Interpretation: Treatment of moderate-to-severe migraines in the ED would benefit from low-dose dexamethasone which mitigates potential adverse events from higher doses and alternative abortive agents should be considered to improve sustained headache relief.  

By: Dr. Amanda Mattice 

JC Supervisor: Dr. Jeff Perry