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.
Aspirin is First-Line Treatment for Migraine and Episodic Tension-Type Headache Regardless of Headache Intensity
Version of Record online: 29 AUG 2011
© 2011 American Headache Society
Headache: The Journal of Head and Face Pain
Volume 52, Issue 1, pages 48–56, January 2012
How to Cite
Lampl, C., Voelker, M. and Steiner, T. J. (2012), Aspirin is First-Line Treatment for Migraine and Episodic Tension-Type Headache Regardless of Headache Intensity. Headache: The Journal of Head and Face Pain, 52: 48–56. doi: 10.1111/j.1526-4610.2011.01974.x
- Issue online: 23 JAN 2012
- Version of Record online: 29 AUG 2011
- Accepted for publication June 6, 2011.
- tension-type headache;
- stratified care;
- stepped care
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.