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• Step‐up across attacks — a patient tries simple analgesics exclusively for the first three
attacks: if there has been no benefit from simple analgesia over the trial period, then a
triptan is used for all further attacks.
The US Headache Consortium (Silberstein, 2000) and European Federation of Neurological
Societies (Evers et al, 2006) have recommended a ‘stratified care’ approach; later British
guidelines promote the use of ‘step‐up’ regimens during each attack (Steiner et al, 2007).
Simple analgesics
Patients who experience mild migraine‐related headache and disability may be effectively
treated with simple analgesics, either alone or in combination with an antiemetic. European
consensus guidelines recommend the routine, early use of metoclopramide (or domperidone
in children) (Evers et al, 2006).
Combined soluble aspirin 900 mg and metoclopramide 10 mg was of similar analgesic efficacy
to sumatriptan in mild acute migraine (Oldman et al, 2002 Level I) and may be considered first‐
line treatment. Effervescent aspirin 1000 mg was as effective as sumatriptan 50 mg orally,
with fewer side effects (Lampl et al, 2007 Level I). Ibuprofen (200 to 400 mg) was effective in
achieving pain‐free status within 2 hours, but was no different to placebo for pain outcomes
at 24 hours (Suthisisang et al, 2007 Level I). Paracetamol 1000 mg was effective, usually for mild‐
to‐moderate migraine (Lipton, Baggish et al, 2000 Level II).
A paracetamol‐aspirin‐caffeine combination was superior to placebo and each component
drug alone in terms of analgesia and time to effect (Diener et al, 2005 Level II). It was also more
effective than oral sumatriptan 50 mg in the early treatment of migraine headache (without
associated nausea, vomiting or disability) (Goldstein et al, 2005 Level II) and was better than
ibuprofen in terms of analgesic endpoints and speed of onset (Goldstein et al, 2006 Level II).
Combined tramadol and paracetamol was superior to placebo for improved migraine
headache outcomes to 24 hours and reduced photo/phonophobia (but not nausea) at 2 hours
(Silberstein et al, 2005 Level II).
Dipyrone was also effective for the treatment of migraine and episodic TTHs (Ramacciotti et al,
2007 Level I). Simple analgesics for the treatment of migraine
CHAPTER 9 Analgesic regimen NNT* Source
Table 9.2

Oldman et al, 2002 Level I
3.2
Aspirin 600 to 900 mg
+metoclopramide 10 mg
Paracetamol 1000 mg
8.0
Suthisisang et al, 2007 Level I
Ibuprofen 200 to 400 mg 5.2 Lipton, Baggish et al, 2000 Level II
* Simple analgesics for the treatment of migraine: 2‐hour pain response (nil or mild residual headache at 2 hours).
Over‐the‐counter analgesics
Sixty percent of patients treat their migraines exclusively with over‐the‐counter (OTC)
analgesics; however most trials of OTC medications excluded patients with severe headaches
and related symptoms (nausea and vomiting) or disability.
When data from 11 trials of adequate study design were combined, OTC analgesics such as
paracetamol (alone or in combination with caffeine), aspirin (alone or in combination with
either caffeine and/or paracetamol) and ibuprofen, were more effective than placebo at
reducing moderate‐to‐severe headache (mild or no pain) within 2 hours, with a significant
minority of patients achieving pain‐free status within 2 hours (Wenzel et al, 2003 Level I).
Up to 76% of patients returned to normal functioning after 2 hours, especially if their migraine

262 Acute Pain Management: Scientific Evidence