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Aspirin first for migraine regardless of pain intensity: report

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Aspirin should be tried first in patients with migraine and episodic tension-type headache (ETTH) no matter how bad initial symptoms are, advise the authors of paper online August 29 in the journal Headache.

In a review of individual patient data from clinical treatment trials, they found that the intensity of the headache before treatment did not predict success or failure of aspirin therapy.

Dr. Christian Lampl, of the Department of Neurology, Pain and Headache Center, Konventhospital Barmherzige Brueder, Linz, Austria and colleagues say this finding does not support the stratified care approach to migraine.

The stratified care approach chooses between symptomatic treatments (such as aspirin) and triptans as first-line therapy on a case-by-case basis according to perceived headache severity. The stepped care approach, on the other hand, starts with symptomatic treatment and reserves triptans for patients who fail to get adequate relief.

Dr. Lampl’s team reviewed six clinical trials of aspirin 1000 milligrams in 2,079 patients with moderate or severe migraine and one of aspirin 500 and 1000 milligrams in 325 patients with moderate or severe ETTH.

The analysis failed to show any clear relationship between baseline headache intensity and efficacy of aspirin, they report.

“In migraine, there was barely a trend toward reduced efficacy of aspirin, measured as headache relief at 2 hours, in severe compared with moderate pre-treatment headache,” they note.

“On the International Headache Society-preferred endpoint of pain freedom at 2 hours, pre-treatment headache intensity had no influence. In ETTH, severe pre-treatment headache did not, at all, predict treatment failure: all trends were in the opposite direction,” they report.

They conclude, therefore, that pre-treatment headache intensity “is not an arguable basis for stratified care in migraine.

“Neither is the assumption linking more severe migraine with greater need for triptan therapy, since need for a treatment is underpinned not by illness severity but by expectation of benefit from the treatment,” they charge.

Dr. Lampl and colleagues argue that if triptans were clearly more effective than symptomatic treatment such as aspirin, “then triptans should, all else being equal, be first-line treatment for migraine, which is painful and disabling and demands best treatment in all cases.”

However, they point out that the formal evidence of triptan superiority is “weak, and not all else is equal.” For example, adverse effects with triptans are common, although usually not serious and triptans are costly.

“In our view, aspirin is first-line treatment for migraine or ETTH regardless of headache intensity,” the authors conclude.

Aspirin is First-Line Treatment for Migraine and Episodic Tension-Type Headache Regardless of Headache Intensity
Headache 2011. Published online August 29, 2011.