IV dexamethasone as adjuvant therapy to metoclopramide for acute posttraumatic headache in the ED : A randomized controlled trial

OBJECTIVE: We conducted a randomized study to determine if, among emergency department (ED) patients with acute posttraumatic headache, the combination of intravenous (IV) metoclopramide plus dexamethasone would result in less headache intensity during the 48 h after ED discharge than IV metoclopramide plus placebo. BACKGROUND: Intravenous metoclopramide can improve acute posttraumatic headache among ED patients, though this benefit is not sustained beyond the ED visit. METHODS: This was a randomized, double-blind, placebo-controlled, parallel group study of IV dexamethasone for acute posttraumatic headache. We enrolled patients who presented to two EDs in the Bronx, NY, with moderate or severe headache that met criteria for acute posttraumatic headache, per the International Classification of Headache Disorders, 3rd edition. All study participants received metoclopramide 10 mg IV. They also were randomized to receive dexamethasone 10 mg IV or placebo (normal saline). The primary outcome was absence of moderate or severe headache within 48 h of ED discharge and no use of analgesic or headache medication within that time. We also report frequency of sustained headache relief. It defined as obtaining and maintaining a headache intensity of mild or none, without the use of rescue medication, for 48 h. RESULTS: Over a 42-month period commencing in June 2021, 2220 patients were approached for participation and 162 were enrolled. At baseline, slightly more patients in the placebo arm reported severe versus moderate pain. No other baseline differences were noted. After accounting for age, sex, and baseline pain intensity, dexamethasone was not associated with the primary outcome (Adjusted odds ratio 1.11, 95% confidence interval [CI] 0.57, 2.19, p = 0.751). Sustained pain relief was reported by 10/77 (13.0%) of dexamethasone participants and 12/79 (15.2%) of placebo participants (95% CI for difference - 2.2%: -13.1, 8.7%). CONCLUSION: Among ED patients with acute moderate or severe posttraumatic headache, one dose of IV dexamethasone did not improve headache outcomes.