Repeated doses of combined oral lysine acetylsalicylate and metoclopramide in the acute treatment of migraine

Fixed drug combinations for the acute treatment of migraine : place in therapy

Fixed drug combinations (FDCs) combine standardised doses of two or more drugs in a single tablet, injection, nasal spray or suppository. FDCs may improve treatment compliance, efficacy or tolerability through a variety of mechanisms. At present, FDCs are commonly used in migraine treatment, and more are in development. This systematic review identified 43 prospective trials of FDCs in use for the acute treatment of migraine. Quantitative combination and analysis of the data were not possible, but results of the review support the following qualitative conclusions. First, many FDCs in use for the acute treatment of migraine are older drugs. In these cases, clinical trial evidence that the FDC is efficacious or has important advantages over its treatment components is lacking. The benefits assumed for some common FDC ingredients such as caffeine and metoclopramide are not clearly confirmed in these trials. Secondly, the use of barbiturate-containing FDCs for the acute treatment of migraine is not evidence based, and these drugs are frequently implicated in the development of dependence or medication-induced headache syndromes. Thirdly, studied opioid-containing FDCs are generally superior to placebo, but evidence regarding the safety and tolerability of their repeated use in the treatment of migraine is lacking; clinical experience dictates caution in the use of these agents. Fourthly, ergotamine-containing FDCs are generally superior to placebo, but perform poorly in comparison with single-agent selective serotonin 5-HT(1B/1D) receptor agonists ('triptans'), NSAIDs or even isometheptene or opioid comparators, and are less well tolerated. Fifthly, the most consistent and impressive evidence of benefit is for NSAID-containing FDCs. These invariably outperform placebo and are equivalent or superior to active comparators. Finally, with renewed interest in the use of FDCs for the acute treatment of migraine, high-quality evidence of a benefit for such treatments is emerging. An FDC containing a triptan and NSAID seems most likely to provide efficacy and tolerability benefits in the acute treatment of migraine. Such an FDC is in development but not yet approved for use.

Prospective, randomised, double blind, controlled comparison of metoclopramide and pethidine in the emergency treatment of acute primary vascular and tension type headache episodes

STUDY OBJECTIVE

To compare analgesic effects of metoclopramide (MTP), pethidine (PET), and combination of metoclopramide-pethidine (M-PET) in the treatment of adult patients with acute primary vascular and tension type headache admitted in the emergency department (ED).

METHODS

All consecutive adult patients admitted into a university hospital ED in six months with acute vascular and tension type headache were recruited. The patients whose complaints had lasted no longer than seven days were randomised to four groups and thereby received 10 mg MTP intravenously plus placebo intramuscularly (MTP), 10 mg MTP intravenously plus 50 mg PET intramuscularly (M-PET), 50 mg PET intramuscularly plus placebo intravenously (PET); and intramuscular and intravenous placebo (PLC) in a blinded fashion. The patients were asked to report the degree of pain at 0, 15, 30, and 45 minutes on visual analogue scale (VAS) and demographic data and any side effects encountered were recorded. Rescue medication was used if required by the patient because of poor pain relief.

RESULTS

Data regarding 336 patients meeting inclusion criteria were analysed. Mean VAS values recorded at 45 minutes were significantly higher in PLC group than in others (p = 0.000). When the PLC group was excluded, VAS scores in MTP and M-PET groups were significantly lower than in PET group (p = 0.038). Though unimportant, the incidence of side effects recorded in PET group was found to be significantly higher than in the other groups (p = 0.003).

CONCLUSION

These data suggest that MTP produces more effective analgesia than PET in both vascular and tension type headache in patients with acute primary headache episodes.

Mouth-dispersible aspirin in the treatment of migraine: a placebo-controlled study

OBJECTIVE

To compare the efficacy of mouth-dispersible aspirin 900 mg and placebo in the treatment of migraine.

BACKGROUND

Aspirin is widely accepted as an effective therapy for migraine. Previous studies have indicated that gastric stasis and delayed gastric emptying, which occur during migraine attacks, delay aspirin absorption. Mouth-dispersible formulations are considered to be more quickly absorbed than solid formulations and, therefore, may be more effective in treating migraine.

DESIGN

Randomized, double-blind, placebo-controlled, crossover study in four specialized migraine clinics in the United Kingdom.

METHODS

One hundred one patients diagnosed with migraine (according to the International Headache Society diagnostic criteria) participated in the study. Patients received either single doses of mouth-dispersible aspirin (3 x 300 mg) or placebo for moderate pain in the treatment of two migraine attacks. Rescue medication could be taken after 2 hours, if required. The primary efficacy parameter was response to therapy at 2 hours posttreatment. Other efficacy parameters were response to treatment, pain-free, and pain intensity at all other time points. Functional disability, nausea, vomiting, photophobia, phonophobia, symptom relief, patient and investigator global evaluation, use of rescue medication, headache recurrence, and palatability and convenience were also recorded.

RESULTS

Of 101 patients, 73 took both treatments. At 2 hours, 48% of patients taking mouth-dispersible aspirin responded, compared to only 19% taking placebo (P =.0005). Mouth-dispersible aspirin was significantly better than placebo for response to treatment (P<.05) and pain intensity difference (P<.01) at all time points from 30 minutes posttreatment; for pain-free (P<.05) and use of rescue medication (P<.01) from 3 hours posttreatment; for headache recurrence (P<.05); and for patients' and investigators' global evaluations of efficacy (P =.0001 in both cases).

CONCLUSIONS

Mouth-dispersible aspirin 900 mg is effective compared with placebo for the treatment of moderate migraine head pain, with relief seen from as early as 30 minutes after taking medication.

Anti-emetics

Nausea and vomiting are common symptoms of migraine, which can be controlled with a variety of anti-emetics including phenothiazines and antihistamines. Metoclopramide and domperidone have an additional prokinetic effect which may be important in migraine to overcome gastric stasis and enhance absorption of oral medication.