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Clinical bottom line
A single oral dose of aspirin 900 mg or 1000 mg is more effective than placebo at resolving migrainous headache pain at 2 h and providing relief that is sustained over 24 h.1 Co-administration of metoclopramide 10 mg may provide additional pain relief and a greater reduction in associated symptoms, especially nausea.1
Migraine is a common, disabling, headache disorder, with considerable social and economic impact on the individual and society. Despite experiencing a high level of disability, most migraine sufferers do not seek professional advice, with many relying on over-the-counter medications, such as aspirin, other non-steroidal anti-inflammatory drugs (NSAIDs), paracetamol and paracetamol with caffeine.
This Cochrane review1 set out to determine the efficacy and tolerability of a single oral dose of aspirin, alone or in combination with an antiemetic, compared with placebo and other active treatments in the treatment of acute migraine headaches in adults.
Cochrane CENTRAL, MEDLINE, EMBASE and the Oxford Pain Relief Database were searched for randomised, double-blind, placebo- or active-controlled studies, using aspirin to treat a discrete migraine headache episode, as defined by the International Headache Society. Inclusion criteria were participants 18 years of age or older, at least 10 participants per treatment arm, dichotomous data reported for at least one study outcome, and an adequate washout between treatments for crossover studies. Antiemetics could be taken up to 30 min before aspirin, or in a single combined formulation with aspirin. All medications had to be self-administered.
Thirteen studies (4222 participants) met the inclusion criteria; all had Oxford Quality Scores of at least three out of five. For all efficacy outcomes, aspirin 900 or 1000 mg was superior to placebo with NNTs of 8.1, 4.9 and 6.6 for 2 h pain-free relief (figure 1), 2 h headache relief and 24 h headache relief, respectively, with aspirin alone versus placebo, and 8.8, 3.3 and 6.2, respectively, with aspirin 900 mg plus metoclopramide versus placebo. Associated symptoms of nausea, vomiting, photophobia and phonophobia were reduced with aspirin compared with placebo, with additional metoclopramide significantly reducing nausea and vomiting compared with aspirin alone. Adverse events were mostly mild and transient, occurring in slightly more patients with aspirin than placebo (NNH 30).
Compared with other active treatments, mainly sumatriptan 50 mg or 100 mg, the only significant differences noted were superior efficacy of sumatriptan 100 mg for pain-free relief at 2 h, and fewer patients experiencing adverse events with aspirin plus metoclopramide than with sumatriptan 100 mg.
Limitations: there were small numbers of events for some analyses limiting certainty of the size of the effect for some outcomes.
In adults suffering acute migraine headaches, a single dose of aspirin, either alone or in combination with metoclopramide, is more effective than placebo at eliminating headache pain at 2 h, and in reducing pain over 24 h. Aspirin appears to be well tolerated in the short term.
Implications for clinical practice
By the time they consult a neurologist, many patients would have unsuccessfully tried to resolve their migraine headaches using a series of over-the-counter medications. For those who have not tried a moderate dose of aspirin, with or without an antiemetic, this would be a reasonable first-line therapy. Selection of the best treatment should be patient-specific, taking into account co-morbid conditions, side-effects, cost and availability.
Implications for research
Further research is needed to establish the relative efficacy of aspirin compared with NSAIDs and other commonly prescribed triptans. Ideally, this should involve head-to-head comparisons with a placebo control for internal validity.
Funding There was no funding support for this summary paper. The original Cochrane review was funded internally by Pain Research Funds (UK) and externally by NHS Cochrane Collaboration Programme Grant Scheme (UK) and NIHR Biomedical Research Centre Programme (UK).
Competing interests VK has no interests to declare. RAM and HJM have consulted for various pharmaceutical companies. RAM and HJM have received lecture fees from pharmaceutical companies related to analgesics and other healthcare interventions. RAM, HJM and SD have received research support from charities, government and industry sources at various times. None had any input into this paper, nor the original Cochrane review, at any stage.
Provenance and peer review Commissioned; externally peer reviewed.
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