A steroid taper is commonly prescribed by neurologists in certain circumstances to break a prolonged migraine cycle. Are you wondering if a course of prednisone for migraine is something you should ask your doctor about?
By the end of this article you will understand the 2 main reasons neurologists prescribe steroids for migraine headaches. You will also learn the answers to the most commonly asked questions about this tool for breaking a difficult migraine cycle.
** This is written from the patient and patient-advocate perspective and is not medical advice. The goal is to help inform you so that you may work with your doctors. Specific questions about medications and whether they are right for you can only be addressed by your doctors.
First, what is Prednisone?
Prednisone is a medication in a group of drugs called corticosteroids or “steroids”, for short.
Neurologists often prescribe other steroids like dexamethasone (Decadron), methylprednisolone (Medrol) but prednisone for migraine tends to be the one that is mentioned most often by patients.
Your doctor may prefer the other steroid forms. Decadron for migraine is probably more frequently given. Additionally, methylprednisolone in “Medrol dose packs,” is a commonly used steroid for migraine relief.
For simplicity, this article will refer to prednisone or “steroids” rather than mention all the different varieties that may be used to break a migraine cycle.
How do steroids work, in general?
These potent medications help in two ways. First, steroids reduce the release of chemicals in the body that cause inflammation and pain. Second, the medication suppresses the immune system. The altered function of white blood cells helps reduce inflammation and the associated pain.
Oral steroids can be helpful for both acute and chronic inflammation. Acute injuries like a swollen, painful knee as well as a bad case of sinusitis or poison ivy are often treated with a short course of steroids.
The goal of the treatment is to minimize the damage that the swollen tissues may be causing. The reduction in swelling and certain chemicals released in the inflammatory process helps relieve pain.
When are steroids for migraine typically prescribed?
The 2 main conditions for which steroids for migraine headaches are often prescribed are status migraine (status migrainosus) and as a short term “bridge therapy” for rebound (medication overuse headache / medication adaptation headache). Steroids are typically only used to break a migraine cycle that has proven to be resistant to other acute treatments.
1- Status Migraine
Someone is considered “in status” when an attack goes beyond 72 hours. There are a number of “cycle breakers” that a general neurologist or headache specialist might suggest before ordering an oral steroid. Triptans, CGRP antagonists, non-steroidal anti-inflammatory medications and anti-nausea medications are typically preferred options.
A short course of prednisone may be used if a migraine attack is close to or beyond the 72 hour mark. The goal is to help you find relief and also prevent the risk for central sensitization and the possible chronification of migraine.
2- Rebound (medication overuse headache / medication adaptation headache)
Through no fault of their own, many people with migraine end up in rebound. Rebound can happen to those with episodic and chronic migraine and sometimes can muddy the proper diagnosis and treatment.
We all just want to feel better and get through our day. Medication overuse headache, now known as medication-adaptation headache is clearly described and discussed in this excellent article from the American Migraine Foundation .
The steroid “bridge”
The role of prednisone for migraine in this situation is as a “bridge therapy.” A doctor skilled in helping a patient in rebound will typically prescribe the steroid and advise them to stop all the medications they have been taking that are associated with rebound like non-steroidal anti-inflammatory drugs (NSAIDs), triptans, butalbital and opioids. There may be medications that must be stopped due to contraindications with steroids, too.
The doctor may also prescribe some medications that are not associated with rebound to help with head pain and other symptoms.
Typically, the short course of tapered steroids acts to break or decrease the intensity of the migraine episode. At times, this bridge may be timed to the start of a new intervention such as Botox.
The topic of rebound is often discussed in our private FaceBook group called Migraine Strong. With help, many can regain control after rebound. Migraine Strong also has 3 other articles on the topic as it is such a prevalent problem in the migraine community. Our goal is to help you understand the vicious cycle of rebound, learn how to escape it and answer the frequently asked questions.
Frequently Asked Questions
General inflammation and neurogenic inflammation are thought to play a role in migraine. Neurogenic inflammation associated with migraine is defined by inflammatory reactions in the trigeminovascular system in response to neuronal activity.
The steroids seem to “turn off” the biochemical reactions that trigger and maintain the unwanted, pain-causing cytokines, proteins and inflammatory enzymes that may be at the root of the migraine event.
Many people with migraine are familiar with anti-inflammatories like ibuprofen and naproxen. These are non-steroidal anti-inflammatory medications or NSAIDs. Steroids work a different angle in the inflammation-fighting process. Even though the steroids and NSAIDS work differently, they are are not to be taken together.
Using steroids for prolonged migraine attacks that are not responding to the first and second lines of treatment has been an accepted treatment for decades.
These medications are not used routinely for relief as they have serious potential side effects and the risks and benefits must be carefully weighed.
Different combinations of medications or “migraine cocktails” are usually tried before using prednisone for migraine.
Typically, we see people being prescribed a Decadron or Medrol dose pack for migraine. These are both brand names for dexamethasone and methylprednisolone, respectively. Whether its prednisone for migraine headaches or one of the other two medications, a “steroid taper” over 3-7 days is commonly ordered.
On day one of the taper, several tablets are taken to give the body a burst of steroid and hopefully get the inflammation to start to subside. Each day the steroid is tapered down.
Oral steroids can help break a migraine cycle from the comfort of your own home. However, there are other times that injected or intravenous steroids are used by doctors to help us find relief.
In the emergency department, intravenous Decadron for migraine may be used as it has been shown to help recurrence of attacks. It is not given for acute migraine relief, rather it helps prevent another attack from recurring.
Some headache specialists and headache centers may use IV steroids as part of an IV cocktail for a patient going through a particularly rough patch.
Nerve blocks are other common uses of steroids for acute migraine relief. The solution injected may include both a local anesthetic and a steroid. Reducing local inflammation in specific areas may help get rid of an active migraine or help minimize a trigger.
For many people, steroids break the misery of the prolonged migraine cycle. And, for some people, in addition to the pain relief, they feel energized and can accomplish some things they hadn’t been doing since the attack began.
Personally, whenever I am on a course of steroids, I find that I am extremely productive and energetic. I wish there wasn’t a significant downside to taking steroids as I truly feel great while taking them.
Steroids are not effective at breaking the migraine flare for everyone. So, if you are about to try this prescription, think positively and hopefully you will be in the group of people who find relief.
Some people may have unpleasant but temporary side effects like trouble sleeping, moodiness, increased appetite and weight gain or a significant sense of agitation. These short term side effects subside when the steroid taper is over.
If you have diabetes or pre-diabetes, remind your doctor as steroids usually increases blood sugar levels. It’s temporary but it may be a concern.
The Ugly –
According to Dr. Alexander Mauskop, in one of his comments in his blog about steroids for migraine, “there is no safe dose of steroid.” Some people have bad reactions from small amounts. There are significant and potentially dangerous side effects from steroids especially when taken frequently and/or long-term including glaucoma, diabetes and osteoporosis. A more in-depth discussion of the potential side effects is in this overview.
Anecdotally, of the 3 writers for Migraine Strong, one does well with steroids, one can have very small amounts and one cannot have any due to side effects.
As with many medications, the time to expect improvement will vary. In general, most migraine specialists will expect results by the second day of the steroid taper. The goal is for the steroid to break the acute migraine cycle within the first couple of days. The dose is slowly decreased to allow your body and/or other medications to kick in.
While doctor’s have their own preferred prescribing habits, a common way of prescribing prednisone for migraine is starting with 60 mg/day for 2 days, then decreasing to 40 mg/day for 2 days and then decreasing to 20 mg/day for 2 days. This has been shown to be effective in breaking headache and migraine from rebound.
When using dexamethasone, not prednisone, some neurologists commonly prescribe 8 mg per day for 4 days to break a non-stop migraine attack that has been going on for 3 or more days.
Corticosteroids are often used to help migraine attacks. There was no medical literature suggesting they trigger migraine.
Understanding all your options for acute migraine relief in order to avoid rebound as well as chronification of migraine is critically important. Given that there are many people without access to general neurologists or specialists, it’s imperative that you educate yourself so you can advocate for yourself. Eileen Zollinger has written some excellent ideas about what to do when you don’t have access to a specialist. Sometimes we have to ask for specific treatments when your providers have not been able to help find the right combination of interventions that work.
Kudos to you for researching this topic and reading this far. It’s a good sign that you WILL get yourself better.
This article has been updated since original published date in 2020.