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.
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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.
The Good-
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.
The Bad-
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.
Final Thoughts
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.
Thank you for this info…I’m unfortunately in a migraine cycle as we speak. My neurologist order a 6 day Medrol dude pack. I’m leery of using it because I’m the past I used it for a sinus infection and had to stop the 2nd day in because it made me feel off and heightened anxiety. But I’m at the point of over 2 weeks of having this migraine that I’m willing to try it. Looking for some positive encouragement! It’s in God’s hands.
Hi Holly. Sorry you are having such a tough time. I understand being cautious about taking steroids. They can be so helpful for some people yet others feel agitated and anxious. If not, maybe your doc has some other options for you. Fingers crossed that you don’t have a negative reaction to the steroid pack this time and that it helps break the cycle. -Danielle
HI DANIELLE I AM ON MY SECOND DAY OF PREDNISONE I’M TAKING FIVE TABLETS EACH DAY FOR FIVE DAYS IT HAS BROKEN MY STATUS MIGRAINE SO FAR WHAT OTHER MEDICATIONS DO YOU PRESCRIBE OR WOULD YOU ORDER AFTER I GET OFF THE PREDNISONE APPRECIATE YOUR HELP
Hi Kevin. Thanks for writing with such good news. Status migraine is so hard so I’m happy you have relief. I wish I had some advice for what might help you as you taper off the steroid. You mention being on it for 5 days with 5 tablets. Usually it’s prescribed as a taper so your body can get used to lower and lower levels without bouncing back up to where you started. If you were in rebound, I highly suggest you ask your neurologist for good alternatives that won’t put you back in rebound. We have several articles on rebound to see if that was part of your status migraine. If rebound was not part of the problem, my best guess is that you would benefit from a neurologist or headache specialist’s advice on a good preventive regimen including magnesium ( https://www.migrainestrong.com/magnesium-and-migraine/ ). I wish I could help with more specifics but that is clearly “out of my lane.” If you are working with a general practitioner, I highly suggest a neurologist. 🙂 I hope you find lasting relief. – Danielle
I’ve had my migraines all my life. I am now almost 58 years old. So tired of this pain. I see a Neurologist also. Please can you help me any suggestions?
Hi Pauline. I’m sorry you aren’t finding relief after so long. I would seek the help of a certified headache specialist. There are so many options and you may just need a new approach. I hope something works for you soon. – Danielle
I was prescribed 5 mils a day of pred yesterday for 10 days . after1 pill my migraine of 3 months on and off but mostly on broke! I was also diagnosed with RA so he wants me to take pred for only 10 days. My question is , how long does the break usually last after completing the prescribed time and how often is it safe to take this dose and 10 day regamin?
Hi Karen- That is great news about such a low dose breaking your migraine cycle. I hope it lasts. I don’t have any data about what percentage of people have a prolonged break from migraine versus those that feel symptoms come back, but I know that relief remains for many people. Of course, it’s not a cure and migraine attacks still happen but the daily cycle is broken for many. Thanks for writing! – Danielle
I have had this rocking, off balance, moving feeling constantly for the past 5 months. Almost constant headaches, hearing loss, etc. I just went to a neurologist and she is almost positive I have “vestibular migraines” she prescribed me prednisone to break the cycle. I am on day 6 of my prednisone. And so far only felt a smidge better once and then all worse from there out. Is there still a chance this medicine will work? Or will this pain stay with me forever??
I’m so tired of feeling sick
I hope the prednisone helped and that you are feeling like you have a bit more control. You will get better. We have a great article on vestibular migraine and different options you can try to feel less dizzy. Hope it helps give you some ideas.
https://www.migrainestrong.com/the-vestibular-migraine-recovery-plan-that-ended-my-daily-dizziness/
Hi Faith–I also have a constant rocking, off balance feeling, with a constant pressure and burning in my ears. I have been diagnosed with chronic vestibular migraine. I have been sick for 10 months. I am now on 50 mg of amitryptiline and hoping that once I get to 100 mg I will feel better. I just started a seven-day treatment of prednisone to try and break the cycle to give me some relief. Like you, I am sick of feeling sick.
Hi
I started on a prednisone course today that will taper over 10 days. I have been in a bad migraine cluster for the past 9 days that is not responding to my current medications. I’m afraid I’m in a rebound phase. How long after you start the steroid, is it typical to start feeling relief?
Thanks!
Dana
Hi Dana. I hope the steroid taper brings your relief. Usually people notice a difference by Day 2. If it doesn’t help there are other ways of breaking the cycle whether it’s rebound or just a bad flare. I hope you are btter soon. -Danielle
My neurologist prescribed me a 6 day met. dose pack of predinisone to break my migraine. It’s worked on my headache but is killing my gut (I have IBS, had abdominal migraines as a child–so weak GI system) which is in a lot of pain and I’m in the bathroom *a lot*. My Dr. is out of town and I can’t find the phone # for the Dr. who is her back up. Can you pls offer some advice?
Thank you so much. -Kathy
Hi Kathy. Sorry you are having pain. I cannot offer individual advice. If I were you, I’d call the office as they likely have contact info for the covering doctors. In the meantime, asking a pharmacist may help. -Danielle
today i went to urgent care b/c of my migraine was going to kill me i took botax injections before a month but it doesn’t help today my urgent care DR prescribe me predinsone for 5 days am still doubt with this medication as well can you recommend me to try for 5 days
Prednisone and other steroids can be so helpful. Botox is also often helpful as a preventive but often needs several months to reduce migraine attacks. I hope you are feeling better by now. – Danielle
Hi, My doctor ordered Prednisone 20mg every day for 5 days, not a taper. Will this regimen work as well as a Prednisone taper for migraines? Also I have severe anxiety and therefore a fear of stetoids. Thank you
It’s certainly worth a try. This regimen may be very helpful for you. If you haven’t started it already, I encourage you to give it a try. – Danielle
My doctor put me on a 3 day “blast” of prednisone to break the cycle. I had 2 horrible days of migraines while on it!! It was terrible. She said this isn’t common. I’m wondering if its because I started with a high dose and tapered off quickly 6o 40 20? Anyone else get migraines while taking prednisone?