Tools for Practice


#95 From Headache to Happiness, How to treat a migraine


CLINICAL QUESTION
Are over-the-counter medications similar in effectiveness to prescription medications?

BOTTOM LINE
Many over the counter medications have similar efficacy to prescription medications in the treatment of acute migraine, including acetaminophen, aspirin, ibuprofen, and naproxen. The combination of acetaminophen, aspirin, and caffeine may offer additional benefit.


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EVIDENCE
Six systematic reviews on common migraine treatments. Numbers Needed to Treat (NNT) are listed for “two hour pain relief” and “two hour pain free” respectively:
  • Acetaminophen 1,000 mg (2,942 patients):1 NNT 5, 12
  • Aspirin 1,000 mg (4,222 patients):2 NNT 5, 9
  • Ibuprofen 400 mg (2,575 patients):3 NNT 4, 8
  • Naproxen 500 mg or 850 mg (2,149 patients):4 NNT 6, 12
  • Sumatriptan 50 mg PO (8,102 patients)5 NNT 4, 7
  • Sumatriptan 100 mg PO (7,811 patients):5 NNT 4, 5
  • Sumatriptan 50-85 mg + Naproxen 500 mg (7,345 patients):6 NNT 4, 5
Randomized controlled trial (RCT) of 1,555 patients compared acetaminophen 500 mg, aspirin 500 mg, and caffeine 130 mg (AAC) to ibuprofen 400 mg:7
  • AAC was superior on weighted sum pain relief score at two hours, p<0.03.
RCT of 171 patients compared AAC to Sumatriptan 50 mg.8
  • AAC was more effective for sum of pain intensity reduction and mean pain relief at both two and four hours, p<0.05.
  • Actual number of patients achieving relief or pain free was not reported for either trial of AAC.
Unpublished data on clinicaltrials.gov9 includes a RCT of 752 patients comparing AAC to Sumatriptan 100 mg.
  • Sumatriptan 100 mg was superior for pain free at two hours, NNT=10.
Context:
  • While the acetaminophen, aspirin, and caffeine combination is available in the United States, it is not available in Canada. The individual components, however, are.
  • Generic sumatriptan 100 mg is approximately 50 times the cost of all components of AAC combined.
  • Up to 7% of patients who use triptans will experience “Triptan Syndrome,” which may include chest and neck tightness, heaviness, paresthesias, and chest pain—but is not associated with cardiac outcomes.10
updated march 8 2017 by evan sehn
September 9, 2013

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Author(s):

  • Christina Korownyk MD CCFP
  • David Ross MD CCFP

1. Derry S, Moore RA, McQuay HJ. Cochrane Database Syst Rev. 2013; (4):CD008040.

2. Kirthi V, Derry S, Moore RA, et al. Cochrane Database Syst Rev. 2013; (4):CD008041.

3. Rabbie R, Derry S, Moore RA. Cochrane Database Syst Rev. 2013; 4:CD008039.

4. Law S, Derry S, Moore RA. Cochrane Database Syst Rev. 2013; 10:CD009455.

5. Derry CJ, Derry S, Moore RA. Cochrane Database Syst Rev. 2014; 5:CD009108.

6. Law S, Derry S, Moore RA. Cochrane Database Syst Rev. 2016; 4:CD008541.

7. Goldstein J, Silberstein SD, Saper JR, et al. Headache. 2006; 46:444-53.

8. Goldstein J, Silberstein SD, Saper JR, et al. Headache. 2005; 45:973-82.

9. Efficacy and Safety of Acetaminophen, Aspirin and Caffeine With Sumatriptan in the Acute Treatment of Migraine. Available from: http://clinicaltrials.gov/ct2/show/record/NCT01248468?sect=X4376015

10. Dodick D, Lipton RB, Martin V, et al. Headache. 2004; 44(5):414-25.

Authors do not have any conflicts of interest to declare.