Aspirin is First-Line Treatment for Migraine and Episodic Tension-Type Headache Regardless of Headache Intensity

Authors

  • Christian Lampl MD,

    Corresponding author
    1. From Department of Neurology, Pain and Headache Center, Konventhospital Barmherzige Brueder, Linz, Austria (C. Lampl); Bayer HealthCare AG, Leverkusen, Germany (M. Voelker); Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway (T.J. Steiner).
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  • Michael Voelker PhD,

    1. From Department of Neurology, Pain and Headache Center, Konventhospital Barmherzige Brueder, Linz, Austria (C. Lampl); Bayer HealthCare AG, Leverkusen, Germany (M. Voelker); Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway (T.J. Steiner).
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  • Timothy J. Steiner MB, PhD

    1. From Department of Neurology, Pain and Headache Center, Konventhospital Barmherzige Brueder, Linz, Austria (C. Lampl); Bayer HealthCare AG, Leverkusen, Germany (M. Voelker); Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway (T.J. Steiner).
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  • Conflict of Interest: Dr. Lampl has received honoraria for planning and conducting clinical trials, participating in advisory board meetings and speaking from Allergan, AstraZeneca, Bayer, Biogen Idec, Bristol-Myers Squibb, GlaxoSmithKline, Grünenthal, Janssen-Cilag, Lilly, MSD, Menarini, Merck-Serono, Mundipharma, Pfizer, and Sanofi-Aventis, and financial support for clinical research from: Allergan, AstraZeneca, Bayer, Gruenenthal, Mundipharma, and Pfizer. Dr. Michael Voelker is an employee of Bayer HealthCare AG. Professor Steiner has received speaker honoraria and/or travel reimbursement from World Headache Alliance, European Headache Federation, British Association for the Study of Headache, Sapienza University Rome, Merck & Co. Inc., GlaxoSmithKline, and Bayer HealthCare; is Associate Editor of Journal of Headache and Pain; serves or has served as consultant to Datamonitor, Bayer HealthCare, MAP Pharmaceuticals Inc., Merck & Co. Inc., and Mundipharma International Limited; and has received research support from the World Headache Alliance, the International Headache Society, and the European Headache Federation.

C. Lampl, Department of Neurology, Pain and Headache Center, Konventhospital Barmherzige Brueder, Seilerstaette 2, A-4020 Linz, Austria, email: christian.lampl@bblinz.at

Abstract

Objectives.— (1) To establish whether pre-treatment headache intensity in migraine or episodic tension-type headache (ETTH) predicts success or failure of treatment with aspirin; and (2) to reflect, accordingly, on the place of aspirin in the management of these disorders.

Background.— Stepped care in migraine management uses symptomatic treatments as first-line, reserving triptans for those in whom this proves ineffective. Stratified care chooses between symptomatic therapy and triptans as first-line on an individual basis according to perceived illness severity. We questioned the 2 assumptions underpinning stratified care in migraine that greater illness severity: (1) reflects greater need; and (2) is a risk factor for failure of symptomatic treatment but not of triptans.

Methods.— With regard to the first assumption, we developed a rhetorical argument that need for treatment is underpinned by expectation of benefit, not by illness severity. To address the second, we reviewed individual patient data from 6 clinical trials of aspirin 1000 mg in migraine (N = 2079; 1165 moderate headache, 914 severe) and one of aspirin 500 and 1000 mg in ETTH (N = 325; 180 moderate, 145 severe), relating outcome to pre-treatment headache intensity.

Results.— In migraine, for headache relief at 2 hours, a small (4.7%) and non-significant risk difference (RD) in therapeutic gain favored moderate pain; for pain freedom at 2 hours, therapeutic gains were almost identical (RD: −0.2%). In ETTH, for headache relief at 2 hours, RDs for both aspirin 500 mg (−4.2%) and aspirin 1000 mg (−9.7%) favored severe pain, although neither significantly; for pain freedom at 2 hours, RDs (−14.2 and −3.6) again favored severe pain.

Conclusion.— In neither migraine nor ETTH does pre-treatment headache intensity predict success or failure of aspirin. This is not an arguable basis for stratified care in migraine. In both disorders, aspirin is first-line treatment regardless of headache intensity.

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