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

Abstract

Background: 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 strategy: We searched Cochrane CENTRAL, MEDLINE, EMBASE and the Oxford Pain Relief Database for studies through 10 March 2010.

Selection criteria: We included randomised, double-blind, placebo- or active-controlled studies using aspirin to treat a discrete 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: 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.Associated symptoms of nausea, vomiting, photophobia and phonophobia were reduced with aspirin compared with placebo, with additional metoclopramide significantly reducing nausea (P < 0.00006) and vomiting (P = 0.002) compared with aspirin alone.Fewer participants needed rescue medication with aspirin than with placebo. Adverse events were mostly mild and transient, occurring slightly more often with aspirin than placebo.

Authors' conclusions: 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.

Figure 1

Methodological quality graph: review authors’ judgements about each methodological quality item presented as percentages across all included studies.

Figure 2

Forest plot of comparison: 1 Aspirin 900 mg or 1000 mg versus placebo, outcome: 1.2 Pain free at 2 hours.

Figure 3

Forest plot of comparison: 2 Aspirin 900 mg plus metoclopramide 10 mg versus placebo, outcome: 2.2 Pain free at 2 hours.

Figure 4

L’Abbé plot showing pain-free at 2 h response in individual studies. Each circle represents one study, with size on the inset scale.

Figure 5

Forest plot of comparison: 3 Aspirin 900 mg or 1000 mg versus active comparator, outcome: 3.2 Pain free at 2 hours.

Figure 6

Forest plot of comparison: 4 Aspirin 900 mg plus metoclopramide 10 mg versus active comparator, outcome: 4.2 Pain free at 2 hours.

Figure 7

L’Abbé plot showing headache response at 2 h in individual studies. Each circle represents one study, with size on the inset scale.

Figure 8

Forest plot of comparison: 5 Aspirin ± metoclopramide versus placebo, outcome: 5.1 Use of rescue medication.

Figure 9

Forest plot of comparison: 6 Aspirin ± metoclopramide versus active comparator, outcome: 6.1 Use of rescue medication.

Figure 10

Response rates for aspirin 900 mg plus metoclopramide 10 mg in consecutive attacks, reported in five studies (from left:Tfelt-Hansen 1995; Chabriat 1994; Thomson 1992; Le Jeunne 1998; Geraud 2002)

Figure 11

Forest plot of comparison: 5 Aspirin ± metoclopramide versus placebo, outcome: 5.2 Any adverse event within 24 hours.

Figure 12

Forest plot of comparison: 6 Aspirin ± metoclopramide versus active comparator, outcome: 6.2 Any adverse event within 24 hours.