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 head_1785 1635..1636
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
1635
an oral solution, recently was found to be
effective for treating moderate or severe acute
migraine headache in 2 large clinical trials.
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 effective than administration of either drug
lining of the stomach or intestine, and this can alone, and there is currently available a
be a particular problem—and even a compound oral medication, Treximet, that
contraindication to NSAID use—for individuals combines an NSAID (naproxen sodium) and a
with peptic ulcer disease, gastroesophageal triptan (sumatriptan).
reflux (GERD), irritable bowel syndrome, or
Treatment Hint: During an acute migraine
other gastrointestinal disorders. “Heartburn”
attack the stomach may not move an orally
and diarrhea are common side effects of the
administered NSAID along to the small
NSAIDs, and fluid retention also may occur
intestine, where the NSAID normally would be
(albeit infrequently with sporadic, “as needed”
absorbed; co-administration of a caffeinated
usage). In rare instances the NSAIDs may
beverage with the NSAID may overcome this
impair the kidneys or liver, but this is much
problem and promote more effective intestinal
more likely to occur in individuals who
absorption and a higher likelihood of a positive
administer an NSAID on a daily or near-daily
treatment response.
basis.

While some patients may find the NSAIDs John F. Rothrock, MD

to be consistently effective even for migraine of Editor-in-Chief, Headache
moderate to severe intensity, these drugs Director, Headache Treatment and Research
typically are more useful when taken early in Center
the migraine attack. Co-administration of an University of Alabama
NSAID and an oral triptan may prove more Birmingham, AL, USA