Aspirin with or without an antiemetic for acute migraine headaches in adults Stable (no update expected for reasons given in 'What's new')

Abstract

Abstract Background

This is an updated version of the original Cochrane review published in Issue 4, 2010 (Kirthi 2010). Migraine is a common, disabling condition and a burden for the individual, health services and society. Many sufferers choose not to, or are unable to, seek professional help and rely on over‐the‐counter analgesics. Co‐therapy with an antiemetic should help to reduce nausea and vomiting commonly associated with migraine headaches.

Objectives

To determine the efficacy and tolerability of aspirin, alone or in combination with an antiemetic, compared to placebo and other active interventions in the treatment of acute migraine headaches in adults.

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Oxford Pain Relief Database, ClinicalTrials.gov, and reference lists for studies through 10 March 2010 for the original review and to 31 January 2013 for the update.

Selection criteria

We included randomised, double‐blind, placebo‐controlled or active‐controlled studies, or both, using aspirin to treat a migraine headache episode, with at least 10 participants per treatment arm.

Data collection and analysis

Two review authors independently assessed trial quality and extracted data. Numbers of participants achieving each outcome were used to calculate relative risk and numbers needed to treat (NNT) or harm (NNH) compared to placebo or other active treatment.

Main results

No new studies were found for this update. Thirteen studies (4222 participants) compared aspirin 900 mg or 1000 mg, alone or in combination with metoclopramide 10 mg, with placebo or other active comparators, mainly sumatriptan 50 mg or 100 mg. For all efficacy outcomes, all active treatments were superior to placebo, with NNTs of 8.1, 4.9 and 6.6 for 2‐hour pain‐free, 2‐hour headache relief, and 24‐hour headache relief with aspirin alone versus placebo, and 8.8, 3.3 and 6.2 with aspirin plus metoclopramide versus placebo. Sumatriptan 50 mg did not differ from aspirin alone for 2‐hour pain‐free and headache relief, while sumatriptan 100 mg was better than the combination of aspirin plus metoclopramide for 2‐hour pain‐free, but not headache relief; there were no data for 24‐hour headache relief.

Adverse events were mostly mild and transient, occurring slightly more often with aspirin than placebo.

Additional metoclopramide significantly reduced nausea (P < 0.00006) and vomiting (P = 0.002) compared with aspirin alone.

Authors' conclusions

We found no new studies since the last version of this review. Aspirin 1000 mg is an effective treatment for acute migraine headaches, similar to sumatriptan 50 mg or 100 mg. Addition of metoclopramide 10 mg improves relief of nausea and vomiting. Adverse events were mainly mild and transient, and were slightly more common with aspirin than placebo, but less common than with sumatriptan 100 mg.

Author(s)

Varo Kirthi, Sheena Derry, R Andrew Moore

Abstract

Plain language summary

Aspirin with or without an antiemetic for acute migraine headaches in adults

This is an updated version of the original Cochrane review published in Issue 4, 2010 (Kirthi 2010); no new studies were found. A single oral dose of 1000 mg of aspirin reduced pain from moderate or severe to none by two hours in approximately 1 in 4 people (24%) taking aspirin, compared with about 1 in 10 (11%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in roughly 1 in 2 people (52%) taking aspirin compared with approximately 1 in 3 (32%) taking placebo. Of those who experienced effective headache relief at two hours, more had that relief sustained over 24 hours with aspirin than with placebo. Addition of 10 mg of the antiemetic metoclopramide substantially increased relief of nausea and vomiting compared with aspirin alone, but made little difference to pain.

Oral sumatriptan 100 mg was better than aspirin plus metoclopramide for pain‐free response at two hours, but otherwise there were no major differences between aspirin with or without metoclopramide and sumatriptan 50 mg or 100 mg. Adverse events with short‐term use were mostly mild and transient, occurring slightly more often with aspirin than placebo, and more often with sumatriptan 100 mg than with aspirin.

Author(s)

Varo Kirthi, Sheena Derry, R Andrew Moore

Reviewer's Conclusions

Authors' conclusions

Implications for practice

Since the last version of this review no new studies were found. Aspirin 900 mg or 1000 mg is an effective treatment for some individuals with acute migraine headaches.Participants in these studies who responded to treatment experienced a reduction in both pain and associated symptoms, such as nausea and photophobia. The addition of 10 mg metoclopramide may provide additional pain relief and greater reduction in associated symptoms, particularly nausea. There was a small increase in the number of adverse events compared to placebo, but most events were mild and transient. Oral sumatriptan 50 mg or 100 mg provided similar efficacy in these studies (although sumatriptan 100 mg was superior to the aspirin plus metoclopramide combination for pain‐free at two hours), but with slightly increased adverse events for sumatriptan 100 mg. Aspirin plus metoclopramide would seem to be a good first‐line therapy for acute migraine attacks in this population, although frequent use over the longer‐term may bring a higher risk of harm. Those who do not experience adequate relief should try an alternative therapy.

Implications for research

Studies directly comparing aspirin with paracetamol (which has a different mode of action), and with other triptans and NSAIDs would help to clarify the relative efficacy of the various treatment options. Ideally these studies would be head‐to‐head comparisons and would include a placebo comparator for internal validity.

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