Headache © 2010 American Headache Society doi: 10.1111/j.1526-4610.2010.01785.x

Headache
© 2010 American Headache Society
Published by John Wiley & Sons, Inc.
doi: 10.1111/j.1526-4610.2010.01785.x
HEADACHE Toolbox
Non-Steroidal
Anti-Inflammatory
Drugs (NSAIDs) for
Acute Migraine
Treatment
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1635..1636
an oral solution, recently was found to be
effective for treating moderate or severe acute
migraine headache in 2 large clinical trials.
While the “triptans”—eg, sumatriptan
(Imitrex), rizatriptan (Maxalt), eletriptan
(Relpax)—have received more promotion and
attention over the 2 decades since they first
became available for general use, the
non-steroidal anti-inflammatory drugs (NSAIDs)
long have been a mainstay of treatment for
acute migraine headache. Perhaps the best
known of the NSAIDs frequently used for that
purpose are ibuprofen (eg, Advil, Motrin), and
naproxen sodium (eg, Aleve, Anaprox), both
available in over-the-counter/non-prescription
and prescription preparations—but
flurbiprofen, diclofenac potassium (eg,
Cataflam), and others also have been
demonstrably effective in treating acute
migraine headache. Indomethacin (eg, Indocin)
is another NSAID widely used for the
treatment of migraine and other primary
headache disorders, and Cambia, a new
powdered formulation of diclofenac potassium
that is to be dissolved in water and taken as
The NSAIDs typically are much less
expensive than the triptans, and in the few
studies that have compared a particular NSAID
with a triptan, the NSAID has performed at
least nearly as well. In addition, compared to
other medications administered for acute
migraine headache, the NSAIDs appear to
possess a relatively low potential for producing
medication overuse headache (often referred
to as “rebound” headache). Finally, and unlike
opioids/opiates (“narcotics”) or headache
preparations containing a barbituate (usually
butalbital; eg, Esgic, Fioricet), use of the
NSAIDs for acute headache treatment does
not appear to predispose to eventual
“chronification” of migraine (ie, the
development of daily or near-daily
headache).
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Virtually all of the NSAIDs may irritate the
lining of the stomach or intestine, and this can
be a particular problem—and even a
contraindication to NSAID use—for individuals
with peptic ulcer disease, gastroesophageal
reflux (GERD), irritable bowel syndrome, or
other gastrointestinal disorders. “Heartburn”
and diarrhea are common side effects of the
NSAIDs, and fluid retention also may occur
(albeit infrequently with sporadic, “as needed”
usage). In rare instances the NSAIDs may
impair the kidneys or liver, but this is much
more likely to occur in individuals who
administer an NSAID on a daily or near-daily
basis.
While some patients may find the NSAIDs
to be consistently effective even for migraine of
moderate to severe intensity, these drugs
typically are more useful when taken early in
the migraine attack. Co-administration of an
NSAID and an oral triptan may prove more
effective than administration of either drug
alone, and there is currently available a
compound oral medication, Treximet, that
combines an NSAID (naproxen sodium) and a
triptan (sumatriptan).
Treatment Hint: During an acute migraine
attack the stomach may not move an orally
administered NSAID along to the small
intestine, where the NSAID normally would be
absorbed; co-administration of a caffeinated
beverage with the NSAID may overcome this
problem and promote more effective intestinal
absorption and a higher likelihood of a positive
treatment response.
John F. Rothrock, MD
Editor-in-Chief, Headache
Director, Headache Treatment and Research
Center
University of Alabama
Birmingham, AL, USA