Aspirin should be tried first in patients with migraine and episodic tension-type headache (ETTH), no matter how bad the initial symptoms are, say the authors of an online paper in Headache.

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

Stratified care approach

Lead author Dr Christian Lampl of 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 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.

“Proponents of stratified care,” Dr Lampl told Reuters Health, “assert that patients should take, first, whatever treatment is most likely to bring them most benefit. This is an assertion few would question. The fallacy in this stems from the supposition that severity underpins need.”

Study review

His group reviewed six trials of aspirin 1000mg in 2,079 patients with moderate or severe migraine. They also looked at a single trial of aspirin 500 and 1000mg in 325 patients with moderate or severe ETTH.

Their study failed to show any clear relationship between baseline headache intensity and efficacy of aspirin.

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

“On the International Headache Society-preferred endpoint of pain freedom at two 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.

Headache intensity

The investigators 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.”

However, the formal evidence of triptan superiority is “weak, and not all else is equal”, they say. 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.

Dr Lampl added, “The only basis for preferring a triptan in individualised care is that symptomatic treatments such as aspirin have been found, in that individual, not to be effective. Stepped care does this; stratified care does not.” – (Megan Brooks/Reuters Health, September 2011)
SOURCE: Headache 2011.

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