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Evidence summaries

Paracetamol with or Without an Antiemetic for Acute Migraine

Paracetamol 1 000 mg is effective in acute migraine, and the addition of metoclopramide 10 mg gives short-term efficacy equivalent to oral sumatriptan 100 mg. Adverse events with paracetamol do not differ from placebo. Level of evidence: "A"

Use paracetamol as first-line treatment in acute migraine with or without an antiemetic for patients who are responsive to this drug.

A Cochrane review[Abstract] http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD008040/frame.html 1 included 10 RCTs with a total of 2 769 participants (4 062 attacks) with migraine. Paracetamol 1 000 mg, alone or in combination with metoclopramide, was compared with placebo or sumatriptan 100 mg.

  • Paracetamol vs. placebo (4 trials, n=1 293): For all efficacy outcomes paracetamol was superior, when medication was taken for moderate to severe pain. Risk ratio (RR) for being free of pain at 2 hours was 1.80 (95% CI 1.24-2.62) with NNT of 12 (7.5 to 32) (3 trials, n=717). RR for one-hour pain relief was 2.0 (95% CI 1.5 to 2.6) with NNT of 5.2 (3.8 to 8.1) (2 trials, n=635). RR for 2-hour pain relief was 1.6 (95% CI 1.3 to 1.8), giving an NNT 5.0 (95% CI 3.7 to 7.7) (3 trials, n=717). Nausea, photophobia and phonophobia were reduced more with paracetamol at 2 hours (NNTs of 7 to 11). More individuals were free of any functional disability at 2 hours with paracetamol (RR 0.87, 95% CI 0.81 to 0.94; NNT 10; 95% CI 6.0 to 22; 3 trials, n=717). Fewer participants needed rescue medication over 6 hours (RR 0.59, 95% CI 0.47 to 0.74; NNT 6, 95% CI 4,1 to 10; 2 trials, n= 635).
  • Paracetamol 1 000 mg plus metoclopramide 10 mg vs. oral sumatriptan 100 mg (2 trials, n=1 140): There was no significant difference for 2-hour headache relief (RR 0.93, 95% CI 0.81 to 1.1). There were no 2-hour pain-free data. There was no significant difference for relief of "light/noise sensitivity" at 2 hours (RR 0.87, 95% CI 0.77 to 0.98), but slightly more individuals needed rescue medication over 24 hours with the combination therapy (RR 1.2, 95% CI 1.0 to 1.4; NNT 17, 95% CI 9.0 to 210).Adverse event rates were similar between paracetamol and placebo, and between paracetamol plus metoclopramide and sumatriptan. No serious adverse events occurred with paracetamol alone, but more "major" adverse events occurred with sumatriptan than with the combination therapy (NNH 32, 95% CI 18 to 112).

References

  • Derry S, Moore RA. Paracetamol (acetaminophen) with or without an antiemetic for acute migraine headaches in adults. Cochrane Database Syst Rev 2013;4():CD008040. [PubMed]

Primary/Secondary Keywords