Treatment of Severe Headache with Prednisone

First-Line Treatments

The American College of Physicians and other guideline societies recommend NSAIDs (aspirin, ibuprofen, naproxen sodium, diclofenac potassium) as the first-line treatment for mild to moderate migraine attacks 2, 3
The American Academy of Neurology recommends triptans (sumatriptan, rizatriptan, zolmitriptan, etc.) as second-line therapy when NSAIDs are ineffective 2, 4
The American College of Physicians recommends combination therapy of a triptan with an NSAID or acetaminophen for patients who do not achieve sufficient pain relief with either medication alone 3

The American Headache Society recommends CGRP antagonists (gepants) such as rimegepant, ubrogepant, or zavegepant for patients who don't respond to or cannot tolerate NSAIDs and triptans 3, 1
The American Academy of Family Physicians recommends dihydroergotamine (DHE), particularly in intranasal formulation, for efficacy and safety 4, 1
The American College of Physicians recommends lasmiditan (ditan) for moderate to severe acute episodic migraine when other options are contraindicated or ineffective 3, 1

The American College of Physicians states that systemic steroids may be appropriate for status migrainosus - severe, continuous migraine lasting up to one week that has not responded to standard treatments 1
The American Academy of Neurology notes that prednisone is not mentioned in the primary treatment algorithms for typical migraine attacks in recent guidelines 2, 3, 4

The American Academy of Neurology recommends limiting use of acute treatments to no more than twice a week to prevent medication-overuse headaches 4
The American College of Physicians recommends monitoring for medication overuse headache, which can occur with frequent use of acute medications (≥15 days per month with most medications; ≥10 days per month with triptans) 3, 1
The American Academy of Family Physicians recommends considering preventive therapy to reduce frequency and severity of attacks if first and second-line treatments fail 3, 4
The American College of Physicians recommends non-oral routes of administration when nausea or vomiting are significant components of migraine attacks 4
The American Academy of Neurology recommends avoiding opioids and butalbital-containing medications for routine migraine treatment as they can lead to dependency, rebound headaches, and eventual loss of efficacy 3, 1