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 mg to mg taken by mouth. In September , we searched the medical literature and found five studies involving participants looking at aspirin for frequent episodic tension-type headache.
About participants were involved in comparisons between aspirin at doses between mg and mg and placebo a dummy tablet.
Headache Management - Headache Australia
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. 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 mg, about 10 participants in used additional painkillers, compared with 30 in with placebo very low quality evidence.
At the end of the study 55 in participants were 'satisfied' with treatment compared with 37 in with placebo very low quality evidence. About 15 in people taking aspirin mg reported having a side effect after one dose, which was the same as with placebo low quality 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. A single dose of aspirin between mg and mg provided some benefit in terms of less frequent use of rescue medication and more participants satisfied with treatment compared with placebo in adults with frequent episodic TTH who have an acute headache of moderate or severe intensity.
There was no difference between a single dose of aspirin and placebo for the number of people experiencing adverse events. The amount and quality of the evidence was very limited and should be interpreted with caution. Tension-type headache TTH affects about 1 person in 5 worldwide. It is divided into infrequent episodic TTH fewer than one headache per month , frequent episodic TTH two to 14 headache days per month , and chronic TTH 15 headache days per month or more.
Aspirin is one of a number of analgesics suggested for acute treatment of episodic TTH. To assess the efficacy and safety of aspirin for acute treatment of episodic tension-type headache TTH in adults compared with placebo or any active comparator.
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We sought unpublished studies by asking personal contacts and searching online clinical trial registers and manufacturers' websites. We included randomised, double- blind , placebo -controlled studies parallel-group or cross-over using oral aspirin for symptomatic relief of an acute episode of TTH. Studies had to be prospective, with participants aged 18 years or over, and include at least 10 participants per treatment arm. Two review authors independently assessed studies for inclusion and extracted data.
For various outcomes predominantly those recommended by the International Headache Society IHS , we calculated the risk ratio RR and number needed to treat for one additional beneficial outcome NNT , one additional harmful outcome NNH , or to prevent one event NNTp for oral aspirin compared to placebo or an active intervention.
Primary Headache Disorders
We included five studies enrolling adults with frequent episodic TTH; participants took medication, of which were included in comparisons of aspirin mg with placebo , and in comparisons of aspirin mg or mg with placebo. Not all of these participants provided data for outcomes of interest in this review.
Four studies specified using IHS diagnostic criteria; one predated commonly recognised criteria, but described comparable characteristics and excluded migraine. Recommendations Major Recommendations. Headache severity and effect of the headaches on work and family activities Acute and preventive medications tried in the past, and response to these medications and side effects Presence of co-existent conditions that may influence treatment choice insomnia, depression, anxiety, hypertension, asthma, and history of heart disease or stroke Refer to Appendix B: Headache History Guide in the original guideline document.
EO GDG Do Physical Examination Patients presenting to a healthcare provider for the first time with headache, or with a headache that differs from their usual headache , should have a physical examination that includes the following: 1 a screening neurological examination; 2 a neck examination; 3 a blood pressure measurement; 4 a focused neurological examination, if indicated; and 5 an examination for temporomandibular disorders, if indicated.
CS G4 Do Screening Neurological Examination The screening neurological examination should consist of the following: General assessment of mental status Cranial nerve examination: fundoscopy, examination of pupils for symmetry and reaction to light, eye movements, visual field examination, and evaluation of facial movement for asymmetry and weakness Assessment of all four limbs for unilateral weakness, reflex asymmetry, and evaluation of coordination in the upper limbs Assessment of gait, including heel-toe walking tandem gait EO G4 Do Neck Examination Physical examination of patients with headache should include an assessment of neck posture and range of motion, and palpation for muscle tender points.
EO GDG Do Examination for Temporomandibular Disorders In the patient with headache and associated jaw complaints, the physical examination should include clinical assessment of jaw movements and palpation of the muscles of mastication for tender points. Refer to "Management of Migraine Headache," below. NRCS G4 Diagnose episodic tension-type headache if headache attacks are not associated with nausea, and have at least two of the following: 1 bilateral headache; 2 non-pulsating pain; 3 mild to moderate intensity; and 4 headache is not worsened by activity.
Refer to "Management of Tension-Type Headache," below.
Refer to "Management of Cluster Headache," below; neurologist referral recommended. CS G4 Do Patients with headache on 15 or more days per month for more than 3 months and with a normal neurological examination: Diagnose chronic migraine if their headaches meet migraine diagnostic criteria above or are quickly aborted by migraine specific medications triptans or ergots on 8 days a month or more. EO GDG Chronic migraine with medication overuse if the patient uses ergots, triptans, opioids, or combination analgesics on 10 days a month or more; or uses plain acetaminophen or non-steroidal anti-inflammatory drugs NSAIDs on 15 days a month or more.
Refer to "Management of Medication Overuse Headache," below. EO GDG Chronic migraine without medication overuse if patients do not have medication overuse as defined above. EO GDG Diagnose chronic tension-type headache if their headaches meet episodic tension-type headache diagnostic criteria above , except mild nausea may be present. Refer to "Management of Tension-type Headache," below. EO GDG Do Although chronic migraine and chronic tension-type headache may result in continuous headache in some patients, two other less common headache syndromes should be considered in patients with continuous headache.
Refer to "Other Headache Disorders," below neurologist referral recommended. It is important to consider secondary headaches in these patients. Neurologist referral recommended. EO G4 Secondary Headaches Do Cervicogenic headache should be considered in patients with neck pain and occipital head pain, with or without pain radiation to other head regions or face , when pain is precipitated or aggravated by neck movements or sustained neck postures and there are abnormalities on examination of the neck abnormal movement, muscle tone, or muscle tenderness.
EO GDG Do Post-traumatic headache should be diagnosed when a new headache disorder begins within 7 days of a head injury. EO GDG Patients presenting with severe headache of sudden onset thunderclap headache should be sent to an emergency department with urgent computerized tomography CT capability for immediate investigation to exclude subarachnoid hemorrhage. CS G4 Headache with fever and neck stiffness meningismus : Patients with suspected bacterial meningitis should be sent immediately to an emergency department with urgent CT and lumbar puncture capability for investigation and treatment.
Antibiotic therapy should not be unduly delayed by these investigations.
They should be sent immediately to an emergency department with neuroimaging capability and specialist resources for investigation and treatment. NRCS G4 Acute angle-closure glaucoma: Patients with head pain and signs and symptoms of acute angle-closure glaucoma non-reactive mid-dilated pupil, acutely inflamed eye, and visual disturbance with pain and nausea should be sent immediately for assessment by an ophthalmologist or to an emergency department with the capability to measure intraocular pressure and initiate treatment.
G G4 New headache in patients over 50 years of age with other symptoms suggestive of temporal arteritis: Patients over 50 years of age with new onset headache and other symptoms of temporal arteritis jaw claudication, transient visual loss, etc. NR G4 Papilloedema in an alert patient without focal neurological signs: Patients with papilloedema, a normal level of consciousness, and no focal neurological signs may have benign intracranial hypertension pseudotumour cerebri.
They should have urgent specialist referral and will need urgent neuroimaging. An intracranial space-occupying lesion should be ruled out prior to lumbar puncture to measure cerebrospinal fluid CSF pressure. Further investigation may be required as the differential diagnosis would include cerebral venous sinus thrombosis. EO GDG Elderly patient with new headache and subacute cognitive change: Elderly patients with a new headache and a recent subacute days to weeks decline in cognition may have a subacute or chronic subdural hematoma. A history of head injury is not always present.
CS G4 For headache that worsens on standing, brain MRI scanning with gadolinium enhancement may be needed to look for indirect evidence of a CSF leak dural enhancement, etc. EO GDG Do Cluster Headache and Other Uncommon Primary Headache Syndromes In patients with new onset cluster headache or another trigeminal autonomic cephalalgia, hemicrania continua, or new daily persistent headache, specialist referral should be considered for treatment and investigation.
NR G4 Do Not Do Neuroimaging for Patient Reassurance Clinicians considering neuroimaging primarily for patient reassurance in patients with headache should consider whether this is in the best interest of the patient, and a prudent use of resources, or whether other means of reassurance i. A general exercise program should be considered part of comprehensive migraine management. EO GDG Do Specific Migraine Triggers Patients should be advised to consider whether some of the commonly reported migraine triggers, including food triggers, are important for them.
EO GDG Do Rescue Medication For severe migraine attacks, consider providing an additional rescue medication if the patient's usual acute medication does not work consistently for every attack. SR G3, G4 Patients with recurrence of their migraine attack after initial relief from a triptan should be advised to take a second dose within recommended dosage limits , as this is usually an effective strategy.
RCT G2 Nasal zolmitriptan 5 mg and nasal sumatriptan 20 mg are recommended for acute treatment for all severities of migraine if previous attacks have not been controlled by simple analgesics. SR G2 Subcutaneous sumatriptan 6 mg should be considered for patients with severe migraine, including those in whom other triptan formulations have been ineffective. SR G2 Triptans are vasoconstrictors and should be avoided in patients with cardiovascular disease. Do Triptan and NSAID Combinations In patients with an inadequate response to triptans alone, a combination of sumatriptan 50 mg to mg and naproxen sodium to mg may be more effective.
Domperidone has fewer side effects than metoclopramide. RCT G2 Intravenous metoclopramide 10 mg can be used in the acute treatment of patients with migraine. Side effects include akathisia and dystonia. RCT G1, G3 Do Not Do Ergotamine Ergotamine is not recommended for routine use in patients with acute migraine, although it may be helpful for selected patients where triptans are not an option.
SR G4 Because it is a vasoconstrictor, it should not be used in patients with cerebrovascular or cardiovascular disease.
Oral aspirin for treatment of acute episodic tension-type headache in adults
CS G4 Opioids may be necessary when other medications are contraindicated or ineffective, or as a rescue medication when the patient's usual medication has failed. EO GDG For more information on the use of opioids for chronic non-cancer pain, consult the National Opioid Use Guideline Group's Canadian guideline for safe and effective use of opioids for chronic non-cancer pain guideline endorsed by the College of Physicians and Surgeons of Alberta.
RCT G1 Pharmacological Prophylactic Therapy Do Indications for Migraine Preventive Medication Consider migraine pharmacological prophylactic therapy in the following situations: Recurrent migraine attacks are causing significant disability despite optimal acute drug therapy. The frequency of acute medication use is approaching levels that place the patient at risk for medication overuse headache: Use of acute medication on 10 days a month or more for triptans, ergotamines, opioids, and combination analgesics Use of acute medications on 15 days a month or more for acetaminophen and NSAIDs Recurrent attacks with prolonged aura are occurring hemiplegic migraine, basilar-type migraine, etc.
Contraindications to acute migraine medications are making symptomatic treatment of individual migraine attacks. EO GDG Goals for Migraine Prophylactic Therapy Do Choosing a Specific Migraine Preventive Medication A preventive medication should be chosen based on the following: Evidence for efficacy Side effect profile and contraindications Co-existent medical and psychiatric disorders: The number of medications required can be minimized by using migraine preventive drugs which can also treat other disorders that may co-exist with migraine e.
Some migraine preventive drugs are contraindicated by co-existent disorders e. Ensure that patients have realistic expectations as to what the likely benefits of pharmacological prophylaxis will be. That is: Headache attacks will likely not be abolished completely. It may take 4 to 8 weeks for significant benefit to occur. If the prophylactic drug provides significant benefit in the first 2 months of therapy, this may increase further over several additional months of therapy.