Clinical Question

Is aspirin, with or without an antiemetic, an effective therapy for acute migraine headache in adults?

Evidence-Based Answer

Aspirin, with or without an antiemetic, is an effective treatment for acute migraine headache. Adding the antiemetic metoclopramide (Reglan) significantly reduces migraine-related nausea and vomiting compared with aspirin alone. (Strength of Recommendation: A, based on consistent, good-quality patient-oriented evidence.)

Practice Pointers

Migraines are an exceedingly common and disabling affliction; 16.6% of U.S. adults report having migraines or severe headaches.¹ Direct costs average $1,533 per person annually,² whereas indirect costs are an estimated $12 billion each year.³ Most persons who have migraines do not take preventive medications, but nearly all treat acute attacks. Commonly used treatments include triptans, nonsteroidal anti-inflammatory drugs, acetaminophen, and caffeine. Aspirin and metoclopramide are inexpensive, widely available medications, and the latter may improve outcomes by treating nausea and improving analgesic bioavailability.⁴

This Cochrane review investigated the effectiveness of aspirin, with or without metoclopramide, for the treatment of migraine. More than 4,000 participants in 13 studies were randomized to receive either (1) 900 or 1,000 mg of aspirin with or without 10 mg of metoclopramide, or (2) placebo or 50 to 100 mg of sumatriptan (Imitrex). Six studies with 2,027 participants were pooled and demonstrated that more patients taking aspirin were pain free at two hours (24% vs. 11% of those taking placebo; number needed to treat = 8; 95% confidence interval [CI], 6.4 to 11). Similarly, patients taking aspirin were more likely to achieve headache improvement at two hours (i.e., intensity decreasing from moderate/severe to none/ mild) than those taking placebo (52% vs. 32%; number needed to treat = 5; 95% CI, 4.1 to 6.2). Adding metoclopramide to aspirin therapy was no more effective than aspirin alone for complete pain relief at two hours (two studies, 519 participants), but it was more effective for headache improvement at two hours (three studies, 765 participants). The addition of metoclopramide did not increase the ability of aspirin to keep the patient pain free at 24 hours.

Aspirin and sumatriptan are similarly effective in treating acute migraine. For the outcome “pain free at two hours,” 26% were relieved with aspirin and 32% with sumatriptan (relative benefit = 0.82; 95% CI, 0.65 to 1.03). Although metoclopramide appears to have a minimal role in enhancing analgesia when combined with aspirin, the combination was significantly better than aspirin alone for nausea, a common and disabling symptom of migraine. The findings of this review are consistent with current guidelines that list aspirin among the first-line mono-therapies (i.e., nonsteroidal anti-inflammatory drugs, triptans, and acetaminophen) for acute migraine headache.^5,6 Antiemetics, such as metoclopramide, are primarily considered an adjunct treatment for refractory headache.^5,6 This review provides evidence that metoclopramide should be reserved for those with significant nausea.