Cochrane for Clinicians
Putting Evidence into Practice
Aspirin With or Without an Antiemetic for Acute Migraine Headaches in Adults
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Am Fam Physician. 2014 Feb 1;89(3):176-177.
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Is aspirin, with or without an antiemetic, an effective therapy for acute migraine headache in adults?
Aspirin, with or without an antiemetic, is an effective treatment for acute migraine headache. Adding the antiemetic metoclopramide (Reglan) significantly reduces migraine-related nausea and vomiting compared with aspirin alone. (Strength of Recommendation: A, based on consistent, good-quality patient-oriented evidence.)
Migraines are an exceedingly common and disabling affliction; 16.6% of U.S. adults report having migraines or severe headaches.1 Direct costs average $1,533 per person annually,2 whereas indirect costs are an estimated $12 billion each year.3 Most persons who have migraines do not take preventive medications, but nearly all treat acute attacks. Commonly used treatments include triptans, nonsteroidal anti-inflammatory drugs, acetaminophen, and caffeine. Aspirin and metoclopramide are inexpensive, widely available medications, and the latter may improve outcomes by treating nausea and improving analgesic bioavailability.4
This Cochrane review investigated the effectiveness of aspirin, with or without metoclopramide, for the treatment of migraine. More than 4,000 participants in 13 studies were randomized to receive either (1) 900 or 1,000 mg of aspirin with or without 10 mg of metoclopramide, or (2) placebo or 50 to 100 mg of sumatriptan (Imitrex). Six studies with 2,027 participants were pooled and demonstrated that more patients taking aspirin were pain free at two hours (24% vs. 11% of those taking placebo; number needed to treat = 8; 95% confidence interval [CI], 6.4 to 11). Similarly, patients taking aspirin were more likely to achieve headache improvement at two hours (i.e., intensity decreasing from moderate/severe to none/ mild) than those taking placebo (52% vs. 32%; number needed to treat = 5; 95% CI, 4.1 to 6.2). Adding metoclopramide to aspirin therapy was no more effective than aspirin alone for complete pain relief at two hours (two studies, 519 participants), but it was more effective for headache improvement at two hours (three studies, 765 participants). The addition of metoclopramide did not increase the ability of aspirin to keep the patient pain free at 24 hours.
Aspirin and sumatriptan are similarly effective in treating acute migraine. For the outcome “pain free at two hours,” 26% were relieved with aspirin and 32% with sumatriptan (relative benefit = 0.82; 95% CI, 0.65 to 1.03). Although metoclopramide appears to have a minimal role in enhancing analgesia when combined with aspirin, the combination was significantly better than aspirin alone for nausea, a common and disabling symptom of migraine. The findings of this review are consistent with current guidelines that list aspirin among the first-line mono-therapies (i.e., nonsteroidal anti-inflammatory drugs, triptans, and acetaminophen) for acute migraine headache.5,6 Antiemetics, such as metoclopramide, are primarily considered an adjunct treatment for refractory headache.5,6 This review provides evidence that metoclopramide should be reserved for those with significant nausea.
The views expressed in this article are those of the authors and do not reflect the official policy or position of the U.S. government, Department of the Army, or Department of Defense.
The practice recommendations in this activity are available at http://summaries.cochrane.org/CD008041.
Kirthi V, Derry S, Moore RA. Aspirin with or without an antiemetic for acute migraine headaches in adults. Cochrane Database Syst Rev. 2013;(4):CD008041.
1. Schiller JS, Lucas JW, Ward BW, Peregoy JA. Summary health statistics for U.S. adults: National Health Interview Survey, 2010. Vital Health Stat. 10. 2012;(252):1–207.
2. Stokes M, Becker WJ, Lipton RB, et al. Cost of health care among patients with chronic and episodic migraine in Canada and the USA: results from the International Burden of Migraine Study (IBMS). Headache. 2011;51(7):1058–1077.
3. Hawkins K, Wang S, Rupnow MF. Indirect cost burden of migraine in the United States. J Occup Environ Med. 2007;49(4):368–374.
4. Colman I, Brown MD, Innes GD, Grafstein E, Roberts TE, Rowe BH. Parenteral metoclopramide for acute migraine: meta-analysis of randomised controlled trials. BMJ. 2004;329(7479):1369–1373.
5. Headaches: diagnosis and management of headaches in young people and adults. NICE clinical guideline 150. London, United Kingdom: National Institute for Health and Care Excellence (NICE); 2012. http://www.nice.org.uk/CG150. Accessed August 4, 2013.
6. Beithon J, Gallenberg M, Johnson K, et al. Institute for Clinical Systems Improvement. Diagnosis and treatment of headache. 2013. https://www.icsi.org/_asset/qwrznq/Headache.pdf. Accessed August 4, 2013.
These are summaries of reviews from the Cochrane Library.
The series coordinator for AFP is Corey D. Fogleman, MD, Lancaster General Hospital Family Medicine Residency, Lancaster, Pa.
A collection of Cochrane for Clinicians published in AFP is available at http://www.aafp.org/afp/cochrane.
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