Headache and migraine

PaPaS reviews: interventions for preventing or treating headache and migraine

Correct at September 2017

Acupuncture for the prevention of episodic migraine

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001218.pub3/abstract

Citation: Linde K, Allais G, Brinkhaus B, Fei Y, Mehring M, Vertosick EA, Vickers A, White AR. Acupuncture for the prevention of episodic migraine. Cochrane Database of Systematic Reviews 2016, Issue 6. Art. No.: CD001218. DOI: 10.1002/14651858.CD001218.pub3

Plain Language Summary

Bottom line

The available evidence suggests that a course of acupuncture consisting of at least six treatment sessions can be a valuable option for people with migraine.

Background

Individuals with migraine have repeated attacks of severe headache, usually just on one side and often with vomiting. Acupuncture is a therapy in which thin needles are inserted into the skin at particular points. It originated in China, and is now used in many countries to treat people with migraine. We evaluated whether acupuncture reduces the number of episodes of migraine. We looked at the number of people in whom the number of migraine days per month was reduced by half or more than half.

Key results

For this update, we reviewed 22 trials with 4985 people, published up to January 2016. We omitted five trials from the original review because they included people who had had migraine for less than 12 months. We included five new trials in this update.

In four trials, acupuncture added to usual care or treatment of migraine on onset only (usually with pain-killers) resulted in 41 in 100 people having the frequency of headaches at least halved, compared to 17 of 100 people given usual care only.

In 15 trials, acupuncture was compared with 'fake' acupuncture, where needles are inserted at incorrect points or do not penetrate the skin. The frequency of headaches halved in 50 of 100 people receiving true acupuncture, compared with 41 of 100 people receiving 'fake' acupuncture. The results were dominated by three good quality large trials (with about 1200 people) showing that the effect of true acupuncture was still present after six months. There were no differences in the number of side effects of real and 'fake' acupuncture, or the numbers dropping out because of side effects.

In five trials, acupuncture was compared to a drug proven to reduce the frequency of migraine attacks, but only three trials provided useful information. At three months, headache frequency halved in 57 of 100 people receiving acupuncture, compared with 46 of 100 people taking the drug. After six months, headache frequency halved in 59 of 100 people receiving acupuncture, compared with 54 of 100 people taking the drug. People receiving acupuncture reported side effects less often than people receiving drugs, and were less likely to drop out of the trial.

Our findings about the number of days with migraine per month can be summarized as follows. If people have six days with migraine per month on average before starting treatment, this would be reduced to five days in people receiving only usual care, to four days in those receiving fake acupuncture or a prophylactic drug, and to three and a half days in those receiving true acupuncture.

Quality of the evidence

Overall the quality of the evidence was moderate.

Acupuncture for the prevention of tension-type headache

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007587.pub2/abstract

Citation: Linde K, Allais G, Brinkhaus B, Fei Y, Mehring M, Shin BC, Vickers A, White AR. Acupuncture for the prevention of tension-type headache. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD007587. DOI: 10.1002/14651858.CD007587.pub2

Plain Language Summary

Bottom line

The available evidence suggests that a course of acupuncture consisting of at least six treatment sessions can be a valuable option for people with frequent tension-type headache.

Background

Tension-type headache is a common type of headache. Mild episodes may be treated adequately by pain-killers. In some individuals, however, tension-type headache occurs frequently and significantly impairs their quality of life. Acupuncture is a therapy in which thin needles are inserted into the skin at particular points. It originated in China and is now used in many countries to treat tension-type headache. We found randomised controlled trials to evaluate whether acupuncture prevents tension-type headache. We looked mainly at the numbers of people who responded to treatment, which means a halving of the number of days on which they experienced a headache.

Key results

We reviewed 12 trials with 2349 adults, published up to January 2016. One new trial is included in this updated review.

Acupuncture added to usual care or treatment of headaches only on onset (usually with pain-killers) in two large trials resulted in 48 in 100 participants having headache frequency at least halved, compared to 17 of 100 participants given usual care only.

Acupuncture was compared with 'fake' acupuncture, where needles are inserted at incorrect points or do not penetrate the skin, in six trials. Headache frequency halved in 52 of 100 participants receiving true acupuncture compared with 43 of 100 participants receiving 'fake' acupuncture. The results were dominated by one large, good quality trial (with about 400 participants), which showed that the effect of true acupuncture was still present after six months. There were no differences in the number of side effects of real and 'fake' acupuncture, or the numbers dropping out because of side effects.

Acupuncture was compared with other treatments such as physiotherapy, massage or relaxation in four trials, but these had no useful information.

Quality of the evidence

Overall the quality of the evidence was moderate.

Antiepileptics other than gabapentin, pregabalin, topiramate, and valproate for the prophylaxis of episodic migraine in adults

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010608/abstract

Citation: Linde M, Mulleners WM, Chronicle EP, McCrory DC. Antiepileptics other than gabapentin, pregabalin, topiramate, and valproate for the prophylaxis of episodic migraine in adults. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD010608. DOI: 10.1002/14651858.CD010608

Plain Language Summary

Various medicines, collectively termed 'antiepileptics', are used to treat epilepsy. For several years, three antiepileptics have also been recommended as drugs of first choice (topiramate and valproate) or third choice (gabapentin) for preventing migraine attacks. These three drugs, along with one other (pregabalin), are the subject of separate Cochrane reviews. For the present review, researchers in The Cochrane Collaboration reviewed the evidence about the effect of other antiepileptics in adult patients (≥ 16 years of age) with 'episodic' migraine (headache on < 15 days per month). They examined research published up to 15 January 2013 and found 10 studies of nine different antiepileptics. The majority of these drugs were no better than placebo for migraine prophylaxis (acetazolamide, carisbamate, clonazepam, lamotrigine, oxcarbazepine, and vigabatrin). In one study each, carbamazepine and levetiracetam were better than placebo, and there was no significant difference between zonisamide and topiramate (a drug proven to be effective for migraine prophylaxis). None of these studies was of high methodological quality. The quantity and quality of the evidence were such that no firm conclusions could be drawn about the effect or lack of effect of any of the antiepileptics studied.

Aspirin for acute treatment of episodic tension-type headache in adults

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011888.pub2/abstract

Citation: Derry S, Wiffen PJ, Moore RA. Aspirin for acute treatment of episodic tension-type headache in adults. Cochrane Database of Systematic Reviews 2017, Issue 1. Art. No.: CD011888. DOI: 10.1002/14651858.CD011888.pub2

Plain Language Summary

Bottom line

This review found only very low quality evidence that people with 2 to 14 tension-type headaches a month get good pain relief from taking aspirin 1000 mg or lower doses. There are questions about how studies of this type of headache are conducted. These questions involve the type of people chosen for the studies, and the types of outcomes reported. This limits the usefulness of the results, especially for people who just have an occasional headache.

Background

People with frequent episodic tension-type headache have between 2 and 14 headaches every month. Tension-type headache stops people concentrating and working properly, and results in much disability. When headaches do occur, they get better over time, even without treatment. Aspirin is a commonly used and widely available painkiller, available without prescription (over the counter). The usual dose is 300 mg to 650 mg taken by mouth.

Study characteristics

In September 2016, we searched the medical literature and found five studies involving 1812 participants looking at aspirin for frequent episodic tension-type headache. About 1668 participants were involved in comparisons between aspirin at doses between 500 mg and 1000 mg and placebo (a dummy tablet). The International Headache Society recommends the outcome of being pain free two hours after taking a medicine, but other outcomes are also suggested. No studies reported pain free at two hours, or other recognised outcomes, so there was limited information to analyse for outcomes about how well aspirin works.

Key results

None of the studies reported on participants being pain free at two hours, and only one study reported an outcome we judged equivalent to being pain free or having only mild pain at two hours. For aspirin 1000 mg, about 10 participants in 100 used additional painkillers, compared with 30 in 100 with placebo (very low quality evidence). At the end of the study 55 in 100 participants were 'satisfied' with treatment compared with 37 in 100 with placebo (very low quality evidence). About 15 in 100 people taking aspirin 1000 mg reported having a side effect after one dose, which was the same as with placebo (low quality evidence).

Quality of the evidence

The quality of the evidence was low or very low for the comparisons between aspirin and placebo. Low and very low quality evidence means that we are very uncertain about the results.

Aspirin with or without an antiemetic for acute migraine headaches in adults

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008041.pub3/abstract

Citation: Kirthi V, Derry S, Moore RA. Aspirin with or without an antiemetic for acute migraine headaches in adults. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD008041. DOI: 10.1002/14651858.CD008041.pub3

Plain Language Summary

This is an updated version of the original Cochrane review published in Issue 4, 2010 (Kirthi 2010); no new studies were found. A single oral dose of 1000 mg of aspirin reduced pain from moderate or severe to none by two hours in approximately 1 in 4 people (24%) taking aspirin, compared with about 1 in 10 (11%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in roughly 1 in 2 people (52%) taking aspirin compared with approximately 1 in 3 (32%) taking placebo. Of those who experienced effective headache relief at two hours, more had that relief sustained over 24 hours with aspirin than with placebo. Addition of 10 mg of the antiemetic metoclopramide substantially increased relief of nausea and vomiting compared with aspirin alone, but made little difference to pain.

Oral sumatriptan 100 mg was better than aspirin plus metoclopramide for pain-free response at two hours, but otherwise there were no major differences between aspirin with or without metoclopramide and sumatriptan 50 mg or 100 mg. Adverse events with short-term use were mostly mild and transient, occurring slightly more often with aspirin than placebo, and more often with sumatriptan 100 mg than with aspirin.

Diclofenac with or without an antiemetic for acute migraine headaches in adults

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008783.pub3/abstract

Citation: Derry S, Rabbie R, Moore RA. Diclofenac with or without an antiemetic for acute migraine headaches in adults. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD008783. DOI: 10.1002/14651858.CD008783.pub3

Plain Language Summary

This review found that oral diclofenac potassium 50 mg was an effective treatment for migraine headache, reducing moderate to severe pain to no more than mild pain within two hours in about half (55%) of those treated, to no pain at two hours in about one in five (22%), and to no pain sustained to 24 hours in about the same number (19%). Adverse events were mostly self limiting and of mild or moderate intensity, and were not significantly different from placebo over the short term. Although diclofenac provided good outcomes for some people, almost half did not experience adequate pain relief within two hours, and as few as one in five became pain-free. It is not clear whether the 100 mg dose provides good outcomes for more people. For those who do not experience adequate responses, a different therapy will be needed.

There was no information about different formulations of diclofenac (e.g. suppositories) to treat acute migraine headaches.

Drugs for the acute treatment of migraine in children and adolescents

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005220.pub2/abstract

Citation: Richer L, Billinghurst L, Linsdell MA, Russell K, Vandermeer B, Crumley ET, Durec T, Klassen TP, Hartling L. Drugs for the acute treatment of migraine in children and adolescents. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD005220. DOI: 10.1002/14651858.CD005220.pub2

Plain Language Summary

Background and review question

Migraine is a painful and debilitating disorder that is common in children (under 12 years of age) and adolescents (12 to 17 years of age). Common symptoms reported during a migraine attack are headache, nausea, vomiting, and sensitivity to light and sound. Many treatments for migraine are available, of which the most common are paracetamol (also known as acetaminophen), ibuprofen and other anti-inflammatories, and triptans. Not all triptan medications are approved for use in children or adolescents, and approvals vary from country to country.

Study characteristics

In our review, we looked at 27 randomized controlled trials of drugs compared to placebo to find out which treatments were effective at providing pain freedom two hours after treatment. We also wanted to know what side effects might be caused by the treatments. A total of 7630 children received medication in the studies. The evidence is current to February 2016. Each study had between 13 and 888 participants. Their average age was 12.9 years and ranged from 8.2 to 14.7 years. Nineteen of the studies were funded by the drug manufacturer.

Key results

Ibuprofen appears to be effective in treating children with migraine, but the evidence is limited to only two small trials. Ibuprofen is readily available and inexpensive, making it an excellent first choice for migraine treatment. Paracetamol was not shown to be effective in providing pain freedom in children, but we only found one small study. Triptans are a type of medication designed specifically to treat migraine and are often effective at providing greater pain freedom in children and adolescents. The triptans examined in children included rizatriptan and sumatriptan, while almotriptan, eletriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan were examined in adolescents. The combination of sumatriptan plus naproxen sodium is also effective at treating adolescents with migraine. Overall, there is a risk that the triptan medications may cause minor unwanted side effects like taste disturbance, nasal symptoms, dizziness, fatigue, low energy, nausea, or vomiting. The studies did not report any serious side effects.

Quality of the evidence

The overall quality of the evidence provided by the review was moderate for the triptans, but low for paracetamol and ibuprofen, as we only identified a few studies. More studies need to look at the effects of each of the migraine treatments in children and adolescents separately.

Feverfew for preventing migraine

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002286.pub3/abstract

Citation: Wider B, Pittler MH, Ernst E. Feverfew for preventing migraine. Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD002286. DOI: 10.1002/14651858.CD002286.pub3

Plain Language Summary

Migraine is a common, disabling headache disorder. Feverfew (Tanacetum parthenium L.) is a herbal remedy used for the prevention of migraine attacks. For this update of a previous Cochrane review, we reviewed the available evidence up to January 2015 for or against feverfew in the prevention of migraine and found six studies including 561 participants. Generally the studies were heterogeneous and their results were mixed. The previous version of this review showed no clear benefit of feverfew compared with placebo. We added a new study, which is larger and was carried out to high standards, to this review. It showed that feverfew reduced migraine frequency by a little more than half a migraine (0.6) per month compared to placebo. There was no difference in how severe the pain was, or how long it lasted. These results come from a single study of moderate size, therefore they must be viewed with caution until they are confirmed in other rigorous studies. No major adverse effects were associated with feverfew in the included studies.

Gabapentin or pregabalin for the prophylaxis of episodic migraine in adults

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010609/abstract

Citation: Linde M, Mulleners WM, Chronicle EP, McCrory DC. Gabapentin or pregabalin for the prophylaxis of episodic migraine in adults. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD010609. DOI: 10.1002/14651858.CD010609

Plain Language Summary

Various medicines, collectively termed 'antiepileptics', are used to treat epilepsy. For several years, some of these drugs have also been used for preventing migraine attacks. For the present review, researchers in The Cochrane Collaboration reviewed the evidence about the effects of gabapentin and two related drugs (pregabalin and gabapentin enacarbil) in adult patients (≥ 16 years of age) with 'episodic' migraine (headache on < 15 days per month). They examined research published up to 15 January 2013, along with three unpublished and previously confidential drug company research reports, and found six relevant studies, five of gabapentin and one of gabapentin enacarbil, both over a wide dose range. The studies showed that neither gabapentin nor gabapentin enacarbil was more effective than placebo at reducing the frequency of migraine headaches. Gabapentin commonly caused side effects, especially dizziness and somnolence (sleepiness). No studies of pregabalin were identified, and research on this drug is desirable.

Ibuprofen for acute treatment of episodic tension-type headache in adults

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011474.pub2/abstract

Citation: Derry S, Wiffen PJ, Moore RA, Bendtsen L. Ibuprofen for acute treatment of episodic tension-type headache in adults. Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD011474. DOI: 10.1002/14651858.CD011474.pub2

Plain Language Summary

Frequent episodic tension-type headache (TTH) means having between one and 14 headaches per month. The condition causes much disability, and stops people concentrating and working properly. When headaches occur the pain usually goes away over time.

Ibuprofen is a commonly-used painkiller available without prescription in most parts of the world. The usual dose is 400 mg taken by mouth.

We searched the literature in January 2015 and found 12 studies involved 3094 participants. Of these, about 1800 were included in comparisons between ibuprofen 400 mg and placebo. Others involved lower doses of ibuprofen, or different types of ibuprofen, or were in comparisons with other active drugs.

The outcome preferred by the International Headache Society (IHS) is being pain free after two hours. This outcome was reported by 23 in 100 people taking ibuprofen 400 mg, and in 16 out of 100 taking placebo. The result was statistically significant, but only 7 people (23 minus 16) in 100 benefited specifically because of ibuprofen 400 mg.

The IHS also suggests a range of other outcomes, but few were reported consistently enough for them to be used. People with pain value an outcome of having no worse than mild pain, but this was not reported by any study.

About 4 in 100 people taking ibuprofen 400 mg had an adverse event with ibuprofen, the same as with placebo. There were no serious adverse events.

There are questions about how studies in this type of headache are conducted. These questions involve the type of people chosen for the studies, and the outcomes reported. This limits the usefulness of the results, especially for people who just have an occasional headache.

Ibuprofen with or without an antiemetic for acute migraine headaches in adults

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008039.pub3/abstract

Citation: Rabbie R, Derry S, Moore RA. Ibuprofen with or without an antiemetic for acute migraine headaches in adults. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD008039. DOI: 10.1002/14651858.CD008039.pub3

Plain Language Summary

This is an updated version of the original Cochrane review published in Issue 10, 2010 (Rabbie 2010); no new studies were found. A single oral dose of ibuprofen 200 mg or 400 mg is effective in relieving pain in migraine headaches. Pain will be reduced from moderate or severe to no pain by two hours in just over 1 in 4 people (26%) taking ibuprofen 400 mg, compared with about 1 in 10 (12%) taking placebo. It will be reduced from moderate or severe to no worse than mild pain by two hours in roughly 1 in 2 people (57%) taking ibuprofen compared with approximately 1 in 4 (25%) taking placebo. Of those who experience effective headache relief at two hours, more have that relief sustained over 24 hours with ibuprofen than with placebo. A 200-mg dose is slightly less effective, while soluble formulations give more rapid responses. A single 400-mg dose of ibuprofen has efficacy similar to that shown for a single dose of 1000 mg aspirin in a separate Cochrane review (Kirthi 2013).

Adverse events are mostly mild and transient, occurring in the same proportion of participants treated with ibuprofen and placebo. Very few individuals had serious adverse events or needed to withdraw from these studies because of adverse events.

There is no information for ibuprofen combined with a self-administered antiemetic, and little information comparing ibuprofen with other medications. There were no significant differences between ibuprofen 400 mg and rofecoxib 25 mg (now withdrawn) for 2-hour headache relief, 24-hour sustained headache relief, or use of rescue medication.

Ketoprofen for episodic tension-type headache in adults

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD012190.pub2/abstract

Citation: Veys L, Derry S, Moore RA. Ketoprofen for episodic tension-type headache in adults. Cochrane Database of Systematic Reviews 2016, Issue 9. Art. No.: CD012190. DOI: 10.1002/14651858.CD012190.pub2

Plain Language Summary

Bottom line

This review found that few people with 2 to 14 tension-type headaches a month get good pain relief from taking ketoprofen 25 mg. There are questions about how studies of this type of headache are conducted. These questions involve the type of people chosen for the studies and the types of outcomes reported. This limits the usefulness of the results, especially for people who just have an occasional headache.

Background

People with frequent episodic tension-type headache have between 2 and 14 headaches days every month. Tension-type headache stops people concentrating and working properly, and results in much disability. When headaches do occur, they get better over time, even without treatment.

Ketoprofen is a commonly used painkiller, available by prescription in most parts of the world but without prescription (over-the-counter) in some. The usual dose is 25 mg or 50 mg taken by mouth.

Study characteristics

In May 2016, we searched the medical literature and found four studies involving 1253 participants looking at ketoprofen for frequent episodic tension-type headache. Only a fraction of the participants were involved in comparisons between ketoprofen 25 mg and placebo (a dummy tablet). Results were usually reported two hours after taking the medicine or placebo. The International Headache Society recommends the outcome of being pain-free two hours after taking a medicine, but other outcomes are also suggested. Few studies reported these recommended outcomes, so there was limited information to analyse for some outcomes.

Key results

The outcome of being pain-free at two hours was reported by 27 in 100 people taking ketoprofen 25 mg, and in 16 out of 100 people taking placebo, meaning that only 11 in 100 people benefited because of ketoprofen 25 mg (low quality evidence). The outcome of being pain-free or having only mild pain at two hours was reported by 66 in 100 people taking ketoprofen 25 mg, and in 38 out of 100 people taking placebo (moderate quality evidence), meaning that 28 in 100 people benefited because of ketoprofen 25 mg.

About 14 in 100 people taking ketoprofen 25 mg reported having a side effect, which was slightly more than with placebo (7 in 100 people) (low quality evidence). Most side effects were mild or moderate in intensity. No side effects were serious.

Ketoprofen 25 mg was not different from paracetamol 1000 mg for any measure of headache relief (moderate and low quality evidence), but was associated with more side events (low quality evidence).

Quality of the evidence

The quality of the evidence for being pain-free at two hours was low quality, and for having mild pain at two hours was moderate quality. Moderate quality evidence means that we are reasonably confident about the results. Low quality evidence means that we are not very certain about the results and they could change with more information.

Naproxen with or without an antiemetic for acute migraine headaches in adults

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009455.pub2/abstract

Citation: Law S, Derry S, Moore RA. Naproxen with or without an antiemetic for acute migraine headaches in adults. Cochrane Database of Systematic Reviews 2013, Issue 10. Art. No.: CD009455. DOI: 10.1002/14651858.CD009455.pub2

Plain Language Summary

Migraine is a complex condition with a wide variety of symptoms. For many people the main feature is a painful headache. Other symptoms include feeling sick, vomiting, disturbed vision, and sensitivity to light, sound, and smells.

Non-steroidal anti-inflammatory drugs (NSAIDs) are used to treat migraine headaches. One NSAID is naproxen. On 22 May 2013, we looked for clinical trials where naproxen was used to treat migraine headache. We found six good quality studies with about 2700 people.

Naproxen was more effective than placebo for relieving migraine headache in adults, but only weakly so. From having headache pain described as moderate or severe, about 2 in 10 people (17%) were pain-free at two hours when treated with naproxen. However, about 1 in 10 (8%) were pain-free at two hours when treated with placebo. Almost 5 in 10 had some headache relief with naproxen, and 3 in 10 with placebo. Naproxen is not as good as some other medicines such as ibuprofen or sumatriptan. More dizziness, tingling sensations (paraesthesia), sleepiness (somnolence), nausea, indigestion (dyspepsia), dry mouth, and abdominal discomfort were reported with the 825 mg dose. These effects were generally of mild to moderate severity and rarely led to withdrawal from the studies.

Naproxen is not a good drug for treating migraine at the doses of 500 mg or 825 mg used in the studies we found.

Normobaric and hyperbaric oxygen therapy for the treatment and prevention of migraine and cluster headache

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005219.pub3/abstract

Citation: Bennett MH, French C, Schnabel A, Wasiak J, Kranke P, Weibel S. Normobaric and hyperbaric oxygen therapy for the treatment and prevention of migraine and cluster headache. Cochrane Database of Systematic Reviews 2015, Issue 12. Art. No.: CD005219. DOI: 10.1002/14651858.CD005219.pub3

Plain Language Summary

Background

Migraine and cluster headaches are severe and disabling. Hyperbaric oxygen therapy (HBOT, that is the breathing of pure oxygen at pressures greater than one atmosphere in a pressurised chamber) and normal pressure oxygen therapy (NBOT) can be delivered via a mask at home or in a clinic. These treatments may help to end acute attacks and prevent future attacks.

Results

We originally searched the literature widely in May 2008, and most recently in June 2015. We looked for high quality trials that would help define whether or not there was good evidence for or against the use of oxygen for migraine or cluster headache. We included 11 trials in this review.

Quality of the evidence

We found some low quality evidence to suggest that HBOT relieves pain with acute migraine headaches and possibly cluster headaches, and that NBOT may relieve pain with cluster headache. We found no evidence that either treatment can prevent future attacks. Many migraines can be treated simply with appropriate drug therapy, so further research is needed to help choose the most appropriate patients (if any) to receive HBOT.

Paracetamol (acetaminophen) for acute treatment of episodic tension-type headache in adults

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011889.pub2/abstract

Citation: Stephens G, Derry S, Moore RA. Paracetamol (acetaminophen) for acute treatment of episodic tension-type headache in adults. Cochrane Database of Systematic Reviews 2016, Issue 6. Art. No.: CD011889. DOI: 10.1002/14651858.CD011889.pub2

Plain Language Summary

Bottom line

This review found that few people with two to 14 tension-type headaches a month get good pain relief from taking paracetamol 1000 mg. There are questions about how studies of this type of headache are conducted. These questions involve the type of people chosen for the studies, and the types of outcomes reported. This limits the usefulness of the results, especially for people who just have an occasional headache.

Background

People with frequent episodic tension-type headache have between two and 14 headaches every month. Tension-type headache stops people concentrating and working properly, and results in much disability. When headaches do occur, they get better over time, even without treatment.

Paracetamol is a commonly used painkiller, available without prescription (over the counter) in most parts of the world. The usual dose is 1000 mg (usually two tablets) taken by mouth.

Study characteristics

In October 2015, we searched the medical literature and found 23 studies involving 8079 participants looking at paracetamol for frequent episodic tension-type headache. About 6000 participants were involved in comparisons between paracetamol 1000 mg and placebo (a dummy tablet). Results were usually reported two hours after taking the medicine or placebo. The International Headache Society recommends the outcome of being pain free two hours after taking a medicine, but other outcomes are also suggested. Few studies reported pain free at two hours or other outcomes, so there was limited information to analyse for some outcomes.

Key results

The outcome of being pain free at two hours was reported by 24 in 100 people taking paracetamol 1000 mg, and in 19 out of 100 people taking placebo, meaning that only 5 in 100 people benefited because of paracetamol 1000 mg (high quality evidence). The outcome of being pain free or having only mild pain at two hours was reported by 59 in 100 people taking paracetamol 1000 mg, and in 49 out of 100 people taking placebo (high quality evidence), meaning that only 10 in 100 people benefited because of paracetamol 1000 mg.

About 10 in 100 people taking paracetamol 1000 mg reported having a side effect, which was the same as with placebo (9 in 100 people) (high quality evidence). Most side effects were mild or moderate in intensity. No side effects were serious.

We found a very small amount of information comparing paracetamol 500 mg or 650 mg with placebo, and comparing paracetamol 1000 mg with other painkillers. There was no difference between any of these treatments.

Paracetamol (acetaminophen) with or without an antiemetic for acute migraine headaches in adults

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008040.pub3/abstract

Citation: Derry S, Moore RA. Paracetamol (acetaminophen) with or without an antiemetic for acute migraine headaches in adults. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD008040. DOI: 10.1002/14651858.CD008040.pub3

Plain Language Summary

This is an updated version of the original Cochrane review published in Issue 11, 2010 (Derry 2010). New searches identified one additional study for inclusion; this study compared paracetamol with etodolac and did not contribute to any of the analyses in the review.

A single oral dose of paracetamol 1000 mg will reduce headache pain from moderate or severe to none by 2 hours in 1 in 5 people (19%) taking paracetamol, compared with 1 in 10 (10%) taking placebo. Pain will be reduced from moderate or severe to no worse than mild pain by 2 hours in about 1 in 2 people (56%) taking paracetamol, compared with about 1 in 3 (36%) taking placebo. Too few data were available to assess efficacy beyond 2 hours.

Paracetamol 1000 mg plus metoclopramide 10 mg and oral sumatriptan 100 mg provide similar levels of headache relief at 2 hours. There was insufficient information to compare paracetamol, alone or in combination, with other active treatments.

Adverse events do not differ significantly between paracetamol and placebo. Slightly more serious and/or severe adverse events occur with sumatriptan 100 mg than with paracetamol 1000 mg plus metoclopramide 10 mg.

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) for the prevention of migraine in adults

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002919.pub3/abstract

CitationBanzi R, Cusi C, Randazzo C, Sterzi R, Tedesco D, Moja L. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) for the prevention of migraine in adults. Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD002919. DOI: 10.1002/14651858.CD002919.pub3

Plain Language Summary

Migraine is a common condition that can significantly impair people's quality of life. Individuals who experience frequent or severe migraine may benefit from preventive medications taken prior to an attack and before the pain starts. Studies have suggested the potential role of neurotransmitters in the genesis of headache. Accordingly, drugs that inhibit the passage of neurotransmitters in brain cells and, therefore, increase their levels, have been examined for their potential benefit in preventing migraine. Two classes of inhibitors, the selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), typically used to treat depression, are evaluated in this review.

This is an update of a previous review that included studies on migraine and tension-type headache. This original review has been split in two separate reviews: this update addresses only studies on migraine, while a second focuses on tension-type headache. In November 2014, we identified three new studies. Eight studies were already included in the previous version of the review. Overall, we analysed a total of 585 participants. All the studies had a small number of participants and were conducted over a period of two to three months. Only a few were of high quality.

The results suggest that SSRIs and SNRIs are no better than placebo (sugar pill) for reducing the number of migraine attacks. There were no differences in minor side effects between participants treated with SSRIs or SNRIs versus those treated with placebo. SSRIs and SNRIs seem not to offer advantages when compared to other active treatments, specifically the tricyclic antidepressant amitriptyline. The participants treated with SSRIs or SNRIs suffered fewer minor side effects than those who took amitriptyline, however the number of people who stopped taking one drug or the other due to side effects was approximately equal. These results are based on short-term trials (no more than three months), which are not properly sized and feature serious methodological deficiencies. We did not find studies comparing SSRIs or SNRIs with pharmacological treatments other than antidepressants (e.g. antiepileptics and anti-hypertensives).

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) for the prevention of tension-type headache in adults

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011681/abstract

Citation: Banzi R, Cusi C, Randazzo C, Sterzi R, Tedesco D, Moja L. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) for the prevention of tension-type headache in adults. Cochrane Database of Systematic Reviews 2015, Issue 5. Art. No.: CD011681. DOI: 10.1002/14651858.CD011681

Plain Language Summary

Tension-type headache is a common type of headache that can significantly impair people's quality of life. Individuals who experience frequent or severe headaches may benefit from medications taken before the pain starts. Two classes of medication, the selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), typically used to treat depression, are evaluated in this review.

This is an update of a previous review that included studies on migraine and tension-type headache. The original review has been split into two separate reviews: this update addresses only studies on tension-type headache, while a second focuses on migraine. When we updated this review (November 2014), we identified two new studies. Six studies were already included in the previous version of the review. Overall, we analysed a total of 412 adults participants. All the studies had a small number of participants and were conducted over a period of two to four months. Only a few were of high quality.

Results suggest that SSRIs or SNRIs are no better than placebo (sugar pill) in reducing the number of days with tension-type headache. There were no differences in minor side effects between participants treated with SSRIs or SNRIs versus those treated with placebo. SSRIs and SNRIs do not seem to offer advantages when compared to other active treatments, specifically the tricyclic antidepressant, amitriptyline. The participants treated with SSRIs or SNRIs suffered fewer minor side effects than those who took amitriptyline, however the number of people who stopped taking one drug or the other due to side effects was approximately equal. These results are based on poor quality, small, short-term trials (no more than four months). We did not find a study comparing SSRIs or SNRIs with other medications (e.g. botulinum toxin) or non-drug therapies (e.g. psycho-behavioural treatments, manual therapy, acupuncture).

Sumatriptan (all routes of administration) for acute migraine attacks in adults - overview of Cochrane reviews

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009108.pub2/abstract

Citation: Derry CJ, Derry S, Moore RA. Sumatriptan (all routes of administration) for acute migraine attacks in adults - overview of Cochrane reviews. Cochrane Database of Systematic Reviews 2014, Issue 5. Art. No.: CD009108. DOI: 10.1002/14651858.CD009108.pub2

Plain Language Summary

Migraine is a complex condition with a wide variety of symptoms. For many people, the main feature is a painful, and often disabling, headache. Other symptoms include disturbed vision; sensitivity to light, sound, and smells; feeling sick; and vomiting. Migraine affects about 1 person in 8, mainly women, and mainly in the age range of 30 to 50 years.

Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It can be given by four different routes: by mouth (oral), by injection under the skin (subcutaneous), by nasal spray (intranasal), and by suppositories (rectal). Separate Cochrane reviews for each of these routes provided information on how well sumatriptan worked at reducing headache pain in over 50,000 people with migraine. For oral, subcutaneous, and intranasal sumatriptan there was a large amount of information from good quality trials, but there was relatively little information about rectal administration.

This overview found that a single dose administered via any of these routes was effective in relieving migraine headache pain.

The subcutaneous route provided the best pain relief, with pain reduced from moderate or severe to none by two hours in almost 6 in 10 people (59%) taking the 6 mg dose, compared with approximately 1 in 7 (15%) taking placebo. The most commonly used doses of oral, rectal, and intranasal sumatriptan also provided useful pain relief. The oral 50 mg dose (the least effective of the commonly used dose and route combinations) provided complete relief of pain in almost 3 in 10 people (28%) compared with about 1 in 10 (11%) after placebo. Subcutaneous sumatriptan was also the fastest acting, providing more people with pain relief within one hour of treatment than any other route of administration.

Adverse events, which were mostly of mild or moderate severity and of short duration, were more common with subcutaneously administered sumatriptan and higher doses of oral and intranasal sumatriptan than with other dose and route combinations.

Sumatriptan (intranasal route of administration) for acute migraine attacks in adults

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009663/abstract

Citation: Derry CJ, Derry S, Moore RA. Sumatriptan (intranasal route of administration) for acute migraine attacks in adults. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD009663. DOI: 10.1002/14651858.CD009663

Plain Language Summary

Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is available as a nasal spray, and this route of administration may be preferable for individuals experiencing nausea and/or vomiting, although absorption of the drug occurs primarily in the gut rather than the nasal mucosa. This review found that a single intranasal dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in approximately 2 in 10 people (24%) taking sumatriptan 10 mg, compared with about 1 in 10 (10%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in 5 in 10 people (50%) taking sumatriptan 10 mg, compared with approximately 3 in 10 (32%) taking placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one-third of those who took placebo. The 20 mg dose had greater efficacy, but may be associated with more adverse events, most of which were of short duration and mild or moderate in severity.

Sumatriptan (oral route of administration) for acute migraine attacks in adults

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008615.pub2/abstract

Citation: Derry CJ, Derry S, Moore RA. Sumatriptan (oral route of administration) for acute migraine attacks in adults. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD008615. DOI: 10.1002/14651858.CD008615.pub2

Plain Language Summary

Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is widely available as an oral tablet. This review found that a single dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in about 3 in 10 people (32%) taking sumatriptan 100 mg, compared with about 1 in 10 (11%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in 6 in 10 people (61%) taking sumatriptan 100 mg, compared with about 3 in 10 (32%) taking placebo. Almost a quarter (24%) of people taking sumatriptan 100 mg had freedom from pain at two hours which was sustained during 24 hours without the use of rescue medication, compared with fewer than 1 in 10 (8%) taking placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one-third of those taking placebo. Adverse events were mostly of short duration and mild or moderate in severity, and were experienced by about 4 in 10 (43%) of people taking sumatriptan 100 mg, and by 2 in 10 (23%) taking placebo. The 50 mg dose had slightly lower efficacy, but was associated with fewer adverse events. Treating attacks while pain was still mild was more effective than treating established attacks with moderate or severe pain intensity.

Sumatriptan (rectal route of administration) for acute migraine attacks in adults

Link to Cochrane Library: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009664/abstract

Citation: Derry CJ, Derry S, Moore RA. Sumatriptan (rectal route of administration) for acute migraine attacks in adults. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD009664. DOI: 10.1002/14651858.CD009664

Plain Language Summary

Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is available as a rectal suppository in some countries, and this route of administration may be preferable for individuals experiencing nausea and/or vomiting. This review found that a single dose administered rectally was effective in relieving migraine headache pain and functional disability. Pain was reduced from moderate or severe to no pain by two hours in approximately 2 in 5 people (41%) taking sumatriptan 25 mg, compared with about 1 in 6 (17%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in roughly 2 in 3 people (71%) taking sumatriptan 25 mg, compared with approximately 1 in 3 (30%) taking placebo. In addition to relieving headache pain, sumatriptan 25 mg also relieved functional disability by two hours in about 2 in 5 people (41%), compared with about 1 in 6 (16%) taking placebo. There was not enough evidence to draw any conclusions about the incidence of adverse events or to compare rectal sumatriptan directly with any other active comparators.

Sumatriptan (subcutaneous route of administration) for acute migraine attacks in adults

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009665/abstract

Citation: Derry CJ, Derry S, Moore RA. Sumatriptan (subcutaneous route of administration) for acute migraine attacks in adults. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD009665. DOI: 10.1002/14651858.CD009665

Plain Language Summary

Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is available as a subcutaneous injection, and this route of administration may be preferable for individuals experiencing nausea and/or vomiting, or needing fast relief. This review found that a single subcutaneous dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in almost 6 in 10 people (59%) taking sumatriptan 6 mg, compared with about 1 in 7 (15%) taking placebo, and reduced from moderate or severe to no worse than mild pain by two hours in almost 8 in 10 people (79%) taking sumatriptan compared with about 3 in 10 (31%) taking placebo. Subcutaneous sumatriptan was fast-acting, and the majority of people experiencing pain relief had done so by one hour. About 3 in 10 (31%) people had freedom from pain at two hours which was sustained during the 24 hours postdose without the use of rescue medication, compared with about 1 in 7 (15%) with placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one-third of those taking placebo. Adverse events, most of which were of short duration and mild or moderate in severity, were more frequent with sumatriptan than with placebo.

Sumatriptan plus naproxen for the treatment of acute migraine attacks in adults

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008541.pub3/abstract

Citation: Law S, Derry S, Moore RA. Sumatriptan plus naproxen for the treatment of acute migraine attacks in adults. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD008541. DOI: 10.1002/14651858.CD008541.pub3

Plain Language Summary

Bottom line

The combination of sumatriptan plus naproxen was useful for treating migraine attacks in the studies we found. It was not a lot better than using sumatriptan alone, but it was much better than using naproxen alone. Attacks were more successfully treated when medication was taken early, when pain was mild.

Background

Migraine is a complex condition with a wide variety of symptoms. It affects two to three times more women than men, and is most common in the age range 30 to 50 years. For many people, the main feature is a painful headache. Other symptoms include disturbed vision; sensitivity to light, sound, and smells; feeling sick; and vomiting.

Both nonsteroidal anti-inflammatory drugs (NSAIDs) and the triptan class of drugs are used to treat migraine headaches. This review examined how well naproxen (an NSAID) and sumatriptan (a triptan) work when combined. The combination tablet is not available in most countries, but separate tablets are widely available and can be taken together.

Study characteristics

On 28 October 2015, we looked for clinical trials using sumatriptan plus naproxen to treat migraine headache in adults. People were given either a combination of sumatriptan and naproxen, sumatriptan only, naproxen only, or a placebo (dummy) treatment. They did not know which treatment they were taking, and nor did the health professionals looking after them.

Key results

We found 13 studies, of which 12 (with about 9300 people) provided information on how well the combination treatment worked.

The combination of sumatriptan plus naproxen was better than placebo for relieving acute migraine attacks in adults. When the starting headache intensity was mild, 5 in 10 (50%) of people treated with the combination were pain-free at two hours compared with about 2 in 10 (18%) with placebo. Almost 6 in 10 (58%) people with moderate or severe pain who were treated with the combination had pain reduced to mild or none at two hours, compared with 3 in 10 (27%) with placebo. The combination was also better than the same dose of either drug given alone in these people. Results were 5 in 10 (52%) people with sumatriptan alone or about 4 in 10 (44%) with naproxen alone.

The combination was better than placebo or either drug alone for relief of other migraine symptoms (nausea, sensitivity to light or sound) and loss of ability to function normally. Adverse events of dizziness, tingling or burning of the skin, sleepiness (somnolence), nausea, indigestion (dyspepsia), dry mouth, and chest discomfort were more common with sumatriptan (alone or in combination) than with placebo or naproxen. They were generally of mild to moderate severity and rarely led to withdrawal from the studies.

Quality of the evidence

The studies were carried out to high standards and were generally large enough to give reliable results, so that most of the results for efficacy were of high quality. Results for adverse events were downgraded to moderate quality because there were fewer events.

Topiramate for the prophylaxis of episodic migraine in adults

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010610/abstract

Citation: Linde M, Mulleners WM, Chronicle EP, McCrory DC. Topiramate for the prophylaxis of episodic migraine in adults. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD010610. DOI: 10.1002/14651858.CD010610

Plain Language Summary

Various medicines, collectively termed 'antiepileptics', are used to treat epilepsy. For several years, some of these drugs have also been used for preventing migraine attacks. For the present review, researchers in The Cochrane Collaboration reviewed the evidence about the effects of topiramate in adult patients (≥ 16 years of age) with 'episodic' migraine (headache on < 15 days per month). They examined research published up to 15 January 2013 and found 17 relevant studies. Compared with placebo, topiramate reduced the frequency of migraine headaches by approximately 1.2 per month (nine studies, 1737 participants). Patients were also about twice as likely to reduce the number of their migraine headaches by 50% or more with topiramate than with placebo (nine studies, 1190 participants). Side effects associated with topiramate were common but generally mild; topiramate can, however, cause birth defects and so should be used with caution in women of childbearing age. Further research is needed comparing topiramate with other active drugs used for preventing migraine attacks.

Triptans for acute cluster headache

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008042.pub3/abstract

Citation: Law S, Derry S, Moore RA. Triptans for acute cluster headache. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD008042. DOI: 10.1002/14651858.CD008042.pub3

Plain Language Summary

Cluster headaches are excruciating headaches of extreme intensity. They can last for several hours, are usually on one side of the head only, and affect men more than women. Multiple headaches can occur over several days. Fast pain relief is important because of the intense nature of the pain with cluster headache.

Triptans are a type of drug used to treat migraine. Although migraine is different from cluster headache, there are reasons to believe that some forms of these drugs could be useful in cluster headache. Triptans can be given by injection under the skin (subcutaneously) or by a spray into the nose (intranasally) to produce fast pain relief.

The review found six studies examining two different triptans. The number of people in the studies was limited. Within 15 minutes of using subcutaneous sumatriptan 6 mg, almost 8 in 10 participants had no worse than mild pain, and 5 in 10 were pain-free. Within 15 minutes of using intranasal zolmitriptan 5 mg, about 3 in 10 had no worse than mild pain, and 1 in 10 was pain-free. Adverse events were more common with a triptan than with placebo but they were generally of mild to moderate severity.

Cluster headache is an awful thing to have. More research on how to get better pain relief faster, and to more patients, would be welcome.

Valproate (valproic acid or sodium valproate or a combination of the two) for the prophylaxis of episodic migraine in adults

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010611/abstract

Citation: Linde M, Mulleners WM, Chronicle EP, McCrory DC. Valproate (valproic acid or sodium valproate or a combination of the two) for the prophylaxis of episodic migraine in adults. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD010611. DOI: 10.1002/14651858.CD010611

Plain Language Summary

Various medicines, collectively termed 'antiepileptics', are used to treat epilepsy. For several years, some of these drugs have also been used for preventing migraine attacks. For the present review, researchers in The Cochrane Collaboration reviewed the evidence about the effects of valproate (valproic acid or sodium valproate or a combination of the two) in adult patients (≥ 16 years of age) with 'episodic' migraine (headache on < 15 days per month). They examined research published up to 15 January 2013 and found 10 relevant studies. Compared with placebo, valproate reduced the frequency of migraine headaches by approximately four per month (two studies, 63 participants). Patients were also more than twice as likely to reduce the number of their migraine headaches by 50% or more with valproate than with placebo (five studies, 576 participants). Side effects associated with valproate were common but generally mild; valproate can, however, cause birth defects and so should be used with caution in women of childbearing age. Further research is needed comparing valproate with other active drugs used for preventing migraine attacks.

Zolmitriptan for acute migraine attacks in adults

Link to Cochrane Libraryhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008616.pub2/abstract

Citation: Bird S, Derry S, Moore RA. Zolmitriptan for acute migraine attacks in adults. Cochrane Database of Systematic Reviews 2014, Issue 5. Art. No.: CD008616. DOI: 10.1002/14651858.CD008616.pub2

Plain Language Summary

Migraine is a complex condition with a wide variety of symptoms. It affects about 1 person in 8, mainly women aged 30 to 50 years. For many people, the main feature is a painful, and often disabling, headache. Other symptoms include feeling sick, vomiting, disturbed vision, and sensitivity to light, sound, and smells.

Zolmitriptan is one of the triptan family of drugs. It is used to treat migraine attacks when they occur, not to prevent attacks occurring. It is available as an oral tablet to swallow whole, an oral tablet to dissolve in the mouth, and a nasal spray. This review looked at 25 studies that involved over 20,000 participants reporting the effects of zolmitriptan on migraine attacks. Most information was for tablets taken by mouth. Overall methodological quality of the included studies was good, and treatment group sizes were large enough to avoid major bias. There were inconsistencies in the way use of rescue medication and adverse events were reported.

A single oral dose of zolmitriptan relieved migraine headache pain in some people. Several different pain outcomes were reported.

One outcome was pain reduced from moderate or severe to no pain at all two hours after taking treatment. An oral zolmitriptan 2.5 mg tablet delivered this outcome to about 3 in 10 people (30%), compared with about 1 in 10 (10%) taking placebo.

Another outcome was pain reduced from moderate or severe to no worse than mild pain two hours after taking treatment (called headache relief). An oral zolmitriptan 2.5 mg tablet delivered this outcome to about 6 in 10 people (61%), compared with 3 in 10 (29%) taking placebo.

Slightly better results were obtained with higher doses of 5 mg or 10 mg oral tablets, but the 10 mg dose was associated with more adverse events, most of which were of short duration and mild or moderate in severity. Results for the 5 mg nasal spray were generally similar to those for the oral tablet, but it was significantly better than the tablet at 1 hour.

People with migraine want treatment that eliminates the headache and any associated symptoms quickly (maximum two hours) and prevents it returning (within 24 hours). Results indicate that with the 5 mg dose only 14% of those treated were pain-free at 2 hours with no headache recurrence within 24 hours.

Oral zolmitriptan 2.5 mg and 5 mg provided headache relief at two hours to the same proportion of people (2 in 3) as oral sumatriptan 50 mg, with no difference in numbers experiencing adverse events. The individuals who respond to each drug may not be the same.