Randomized Trial Comparing Low- vs High-Dose IV Dexamethasone for Patients With Moderate to Severe Migraine.

BACKGROUND AND OBJECTIVES: Dexamethasone decreases the frequency of migraine recurrence after emergency department (ED) discharge. However, the optimal dose of dexamethasone is unknown. We hypothesized that dexamethasone 16 mg IV would allow greater rates of sustained headache relief than 4 mg when coadministered with metoclopramide 10 mg IV. METHODS: This was a randomized double-blind study. Adults who presented with a headache meeting International Classification of Headache Disorders, 3rd edition, migraine criteria were eligible if they rated the headache as moderate or severe in intensity. Pain intensity was assessed for up to 2 hours in the ED and through telephone 48 hours and 7 days later. The primary outcome was sustained headache relief. Secondary outcomes included headache relief within 2 hours and the number of headache days during the subsequent week. Relying on a priori criteria, the data safety monitoring committee recommended halting the study early for futility. RESULTS: A total of 1,823 patients were screened, and 209 patients were randomized. The mean age was 38 years (SD 11). One hundred seventy-nine of 209 (86%) identified as women. One hundred fifty-one of 209 (72%) of the population reported severe intensity; the rest reported moderate. Thirty-five of 102 (34%) participants in the metoclopramide +4 mg arm achieved sustained headache relief as did 42/102 (41%) participants in the metoclopramide +16 mg arm (absolute difference 7%, 95% CI -6% to 20%). Headache relief within 2 hours occurred in 77/104 (74%) low-dose and 82/105 (78%) high-dose participants (absolute difference 4%, 95% CI -8% to 16%). During the week after ED discharge, low-dose participants reported a median of 2 headache days (25th, 75th percentile 1, 5); in the high-dose arm, this was also 2 (25th, 75th percentile 0, 4) (mean difference 0.4, 95% CI -0.3 to 1.2). DISCUSSION: When added to 10 mg IV metoclopramide, doses of dexamethasone greater than 4 mg are unlikely to benefit patients in the ED with migraine. TRIAL REGISTRATION INFORMATION: This study was registered at ClinicalTrials.gov on October 2, 2019 (NCT04112823). The first patient was enrolled on December 22, 2019. CLASSIFICATION OF EVIDENCE: This study provides Class I evidence that 16 mg of IV dexamethasone is unlikely to provide greater rates of sustained headache relief than 4 mg of IV dexamethasone among patients in the ED with migraine treated concurrently with IV metoclopramide.

Acute longus colli tendinitis: Case report of a rare cause of neck pain.

Longus colli tendonitis is an uncommon aseptic inflammatory condition that affects the prevertebral longus colli tendon, which is a muscle that courses anteriorly from the level of the C1 to T3 vertebrae (1,2). Although longus colli tendonitis is a self-limited condition, the longus colli muscle is anterior to the prevertebral space and posterior to the pharyngeal constrictors, therefore when inflamed, leads to a myriad of symptoms that often mimic more serious conditions such as retropharyngeal abscess or meningitis (2). We present a case of a 39-year-old white male that presented with neck pain, neck stiffness, and pain with swallowing. Imaging findings on CT and MRI were consistent with a diagnosis of longus colli tendonitis. However, given the patient's presenting symptoms and elevated inflammatory lab markers, he was treated empirically with antibiotic therapy. This case report aims to educate on this condition and to discuss the diagnostic imaging findings to help avoid unnecessary treatments and interventions.

Hand Compartment Syndrome Due to N-acetylcysteine Extravasation.

N-acetylcysteine (NAC) is the antidote for acetaminophen (APAP)-induced hepatotoxicity. Both intravenous (IV) and oral (PO) NAC formulations are available with equal efficacy. Adverse events from either preparation are rare. We describe a hand compartment syndrome after extravasation of NAC requiring emergent fasciotomy during phase three of treatment for suspected APAP toxicity. Extravasation injuries leading to compartment syndrome are rare. It is unclear whether IV NAC induced a direct tissue-toxic insult, or functioned as a space-occupying lesion to cause a compartment syndrome. Compartment syndrome from extravasation of NAC is possible. In cases where IV access is difficult, PO NAC is an alternative.