Migraine headache: Immunosuppressant therapy

Opinion statement

• There is very little literature on the use of immunosuppressant drugs in migraine treatment.

• Immunosuppressive agents are rarely, if ever, used as regular abortive drugs for episodic migraine attacks, and are never used as migraine preventives, because of the risk of side effects that come along with prolonged usage.

• Immunosuppressant drugs have been used in the emergency room as treatment for severe migraine attacks (intravenous corticosteroids), in the treatment of sustained or status migraine (oral or intravenous corticosteroids), in the treatment of drug-overuse headache (oral or intravenous corticosteroids), and in the treatment of immunosuppressant-induced headache in organ transplant recipients.

• Corticosteroids are commonly used as therapy for status migraine. Short courses of rapidly tapering doses of oral corticosteroids (prednisone or dexamethasone) can alleviate status migraine. Intravenous corticosteroids (methylprednisolone) in a single dose (emergency room or outpatient infusion unit) or as several days of repetitive dosing (in-hospital strategy) can be used to break long-lasting migraine attacks.

• A new use for corticosteroids in migraine therapy is to treat drug-overuse headache. Patients with drug-overuse or “rebound⫔eadache will only improve once their symptomatic medications have been discontinued. Stopping “rebounding medications” in the short-term can lead to withdrawal symptoms and a worsening of headache. In the long-term, it will lead to headache improvement. There are both outpatient and inpatient treatment strategies to detoxify patients off of misused medications. Corticosteroids have been used in the management of headache during the detoxification process as both outpatient treatments using short courses of oral corticosteroids or as repetitive intravenous therapy in an inpatient setting.

• Headache is a well-recognized but poorly reported side effect of organ transplantation. The approach to headache evaluation and management in the transplant setting is unique. Physicians must investigate all possible causes of headache from benign side effects of medications to precursors of potentially catastrophic neurologic abnormalities. One needs to think in terms of pharmacologic versus nonpharmacologic causes of headache. Immunosuppressive agents commonly known to cause headache include cyclosporine, tacrolimus (FK506), and muromonab CD3 (OKT3).