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RESEARCH: Ian Colman, Benjamin W Friedman, Michael D Brown, Grant D Innes, Eric Grafstein, Ted E Roberts, and Brian H Rowe Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence BMJ 2008; 336: 1359-1361 [Abstract] [Full text]

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Euphoria, an alternative explanation.

Tehmina Bharucha   (3 August 2008)

Euphoria, an alternative explanation. 3 August 2008
Tehmina Bharucha, Medical Student University of Bristol Send response to journal: Re: Euphoria, an alternative explanation.	Colman et al provide an interesting insight into the treatment of acute migraine. Undoubtedly, migraine is a debilitating illness, widely prevalent and exerting a major impact on patients’ lives. However in view of the limited knowledge of migraine pathogenesis, the proposed mechanism of action of dexamethasone is a contentious issue. Glucocorticoids, including dexamethasone, are routinely administered as therapy for a number of medical conditions(1). Case reports of mood disturbances have been documented ever since their introduction in the late 1940s(2). Two large meta-analyses of the multiple case reports suggest an incidence of severe reactions of 6% and mild-moderate, 28% (3,4). In addition, there is evidence to suggest that effects on mood can occur within 72 hrs with doses of 119 mg/day fluocortolone/ methylprednisolone, equivalent to 24mg/ day dexamethasone(5). A striking dose-response is seen with respect to acute severe psychiatric reactions with prednisone: 1.3% with <40mgs/day (equivalent to 6.4mg/day dexamethasone), 4.6% with 41-80 mg/day, and 18.4% with 80 mg/day(6). Further, hypomania and mania are most commonly cited following acute doses of glucocorticoids, with chronic doses being linked to depression(4). While the number of good clinical research trials in this area are lacking, specifically in terms of 'controlled' trials in 'healthy volunteers', the evidence referred to above does hold significance in interpreting the results of this trial. The dose used in this case, 15mgs dexamethasone, is large enough for the need to consider the incidence of psychiatric reactions. It is possible that the effects reported are secondary to the euphoric effects of dexamethasone. In this case, would these effects deteriorate with chronic dosing? and would the patient be better treated by a psychiatrist or being administered an antidepressant? The side-effects of corticosteroids are diverse and the effects on mood are particularly interesting, largely owing to their abstruse nature. References: 1 Brown, E.S. and Chandler, P., 2001. Mood and cognitive changes during systemic corticosteroid therapy. Primary care companion J Clin Psychiatry. 3(1):17-21 2 Wolkowitz, O., Reus, V., Canick, J., Levin, B., Lupien, S., 1997. Glucocorticoid Medication, memory and steroid psychosis in medical illness. Ann N Y Acad Sci 823:81-96 3 Lewis, D.A., Smith, R.E., 1983. Steroid-induced psychiatric syndromes: a report of 14 cases and a review of the literature. J Affect Disord. 5:319- 332 4 Warrington,T. and Bostwick, M., 2006. Psychiatric adverse effects of corticosteroids. Mayo Clin Proc. 81:1361-1367 5 Naber, D., Sand, P., Heigl, B., 1996. Psychopathological and neuropsychological effects of 8-days’ corticosteroid treatment: a prospective study. Psychoneuroendocrinology. 21:25-31 6 The Boston Collaborative Drug SurveIllance programme, 1972. Acute adverse reactions to prednisone in relation to dosage. Clin Pharmacol Ther. 13:694 -698 Competing interests: None declared