A steroid taper is commonly prescribed by headache specialists 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?
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.
1. What is Prednisone?
Prednisone is a medication in a group of drugs called corticosteroids or steroids, for short. Prescribed steroids are man-made medications that are similar to a natural hormone that is made by our adrenal gland called cortisol.
Neurologists prescribe other steroids like dexamethasone (Decadron), methylprednisolone (Medrol) but prednisone for migraine tends to be the one that is mentioned most by patients and the one many have questions about. Your doctor may prefer the other steroid forms. Decadron for migraine is probably more frequently given.
Steroids are typically prescribed for specific instances of acute inflammation as well as some chronic inflammatory conditions.
2. How Does Prednisone Work?
Steroids are commonly prescribed because of the way they act on inflammation. 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.
Personally, I recall being prescribed oral steroids for flares of bulging discs in my neck, preparation for oral surgery, and a bad case of poison ivy. The steroids worked wonders and brought fast relief. I’ve also had them prescribed for my aging dogs who needed relief from terrible arthritis and to help shrink swelling around a tumor. The positive effect was as wonderfully dramatic for them as it was for me.
General inflammation and neurogenic inflammation is thought to play a potential role in migraine. 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. Triptans, non-steroidal anti-inflammatory medications and anti-nausea medications are preferred acute treatments when they are appropriate to use.
3. When is Prednisone for Migraine Prescribed?
The 2 main conditions for which steroids for migraine are often prescribed are status migraine (status migrainosus) and as a “bridge therapy” for rebound (medication overuse headache).
Someone is considered “in status” when an attack goes beyond 72 hours. There are a number of things that a general neurologist or headache specialist might suggest before ordering an oral steroid, but a short course of prednisone for migraine may be used once you are close to the 72 hour mark or you have gone beyond it. The goal is to help you find relief and also prevent the risk for central sensitization and the possible chronification of migraine.
Rebound (Medication Overuse Headache)
Through no fault of their own, many people with episodic migraine end up in rebound. Rebound also happens to those with 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 is clearly described and discussed in this excellent article from the American Migraine Foundation .
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. 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 as a “bridge” to help the person get through the worst part of the transition to a better acute treatment and preventive treatment plan. 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. Recently, Marina Lentini wrote about her personal experience of regaining 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.
4. How are Steroids for Migraine Prescribed?
Typically, we see people being prescribed a Medrol dose pack or Decadron for migraine. These are both brand names for prednisolone and dexamethasone, respectively. Whether its prednisone for migraine or one of the other two medications, a “steroid taper” over 3-7 days is commonly ordered.
On day one, 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. A prominent headache specialist at the New York Headache Center, Dr. Alexander Mauskop, shares his approach in this short article about steroids and migraine. There are many comments and responses that may help you understand more including his general thoughts on the frequency of using Decadron for migraine and other steroids.
Other Forms and Uses of Steroids for Migraine
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 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 as well as in epidural injections are also times when steroids for migraine may be used for relief. Reducing local inflammation in specific areas may help get rid of an active migraine or help minimize a trigger.
5. The Good, the Bad and the Ugly- What Can You Expect From Prednisone for Migraine.
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 side effects subside when the steroid taper is over.
The Ugly –
According to Dr. 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 4 writers for Migraine Strong, two of us do well with steroids, one can have very small amounts and one cannot have any due to side effects.
Understanding all your options for 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.