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Treatment
Simple analgesics such as nsNSAIDs, paracetamol (Prior et al, 2002 Level II; Steiner et al, 2003
Level II) or aspirin (Steiner et al, 2003 Level II), either alone or in combination, provided effective
analgesia in TTH. Ketoprofen, ibuprofen and naproxen were equally effective and superior to
paracetamol (Lange & Lentz, 1995 Level I; Dahlof & Jacobs, 1996 Level II).
The addition of caffeine to paracetamol, aspirin (Migliardi et al, 1994 Level I) or ibuprofen
(Diamond et al, 2000 Level II) significantly improved analgesia and a paracetamol‐aspirin‐caffeine
combination was more effective than placebo and all three component drugs alone, in terms
of analgesia outcomes and time to effect (Diener et al, 2005 Level II). IV magnesium was
ineffective in treating acute TTH in the emergency department (Frank et al, 2004 Level II).
Acupuncture is an effective non‐pharmacological intervention in TTH (Linde et al, 2009 Level I).
Migraine

Migraine is common, with a prevalence of 6% to 8% in males and 12% to 14% in females (Evers
et al, 2006). Migraine headache is usually unilateral and is often severe, disabling and worsened
by movement. Nausea, vomiting, photophobia and phonophobia are common and 20% of
migraineurs experience an aura.
Most migraines are successfully managed by the patient and his or her family doctor, with up
to 57% of patients not seeking medical attention for significant attacks (Mitchell et al, 1998).
However a small number of patients fail to respond and present for treatment at emergency
departments; approximately 80% of patients have tried their usual medications including
simple analgesics or triptans before presentation (Larkin & Prescott, 1992; Shrestha et al, 1996)
(see Section 9.9.2).
Treatment
The management of migraine includes avoidance of triggers such as sleep deprivation,
stress, sensory stimulation such as bright lights, exercise, alcohol, foods etc. Management of
associated symptoms, particularly nausea and vomiting is important, as is the prevention of
acute recurrence. Environmental modification (quiet dark room) and particularly sleep, is
integral to the successful treatment of migraine (Steiner et al, 2007).
Analgesia outcomes in migraine trials are usually listed as the proportion of patients who
are either:
• pain free at 2 hours; CHAPTER 9
• report significant pain relief at 2 hours (no headache or mild headache); or
• report a sustained response over 24 hours (migraine stays away for at least a day).
Many trials fail to document associated outcomes such as improvement in nausea, vomiting or
disability (Moore et al, 2003).

Strategies for the use of migraine medications
There are three major strategies for the use of analgesics in the treatment of acute migraine
(Lipton, Stewart et al, 2000):
• Stratified care — where for each attack, the severity and disability caused by the migraine
is assessed. The patient uses simple analgesia for a mild attack and a triptan for a severe
attack;
• Step‐up during an attack — for each attack a simple analgesic is always tried first, but the
patient ‘steps up’ to a triptan if there is no relief in 2 hours; and

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