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“Older” Migraine Meds on Trial: What Works?

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Late last year a new study analyzed almost 4.7 million migraine attacks and the medications that patients took. According to those patients, which abortive medications actually worked?

The data was collected from patients’ responses on a smartphone app between 2014 and 2020 (which is why newer medications like gepants and ditans were not included in the study). Dosage was also not taken into consideration. Finally, the “baseline” was ibuprofun. In other words, which medications worked better than (or not as well as) ibuprofen?

However, as you can see, the sample size was huge. So which medications, according to patients, really fought back against an individual migraine attack?

It shouldn’t surprise too many that the migraine-targeting meds worked best:

  • Triptans (e.g. eletriptan, sumatriptan, zolmitriptan) were at the top of the list, working well 5x more often than ibuprofen.
  • Ergots (dihydroergotamine and ergotamine) were 3x more effective than ibuprofen
  • Anti-emetics (anti-nausea medications) were 2.5x more effective
  • Next came opioids, and NSAIDs (not including ibuprofen)

This is not to say that ibuprofen isn’t effective. It was still effective 42% of the time. And it roundly beat acetaminophen (paracetamol), which was effective 37% of the time.

But other similar NSAIDs other than ibuprofen may be worth trying – especially ketorolac, which came out as working 62% of the time, significantly more than its cousin ibuprofen.

Since triptans topped the list, which triptans tended to work the best? Well, it was the ones listed above, but not in that order:

  • eletriptan
  • zolmitriptan
  • sumatriptan

They were all considered effective over 70% of the time – and remember, triptans very much depend on the person, and also how they’re taken.

There’s no doubt that these “older” medications, even ibuprofen, are still helping a lot of people. Lists like this won’t necessarily tell you what will work for you. However, they do give you a place to start.

Your doctor will be able to take more of your personal medical history into consideration when recommending a medication. And there are also risks and side effects to consider, which also vary from person to person.

But if you’re a candidate for a triptan, one of the top three is probably going to be high on your doctor’s list. Tylenol, on the other hand, might be best left on the drugstore shelf, until you’ve tried some better options for migraine.

For the actual study abstract, you can go to Simultaneous Comparisons of 25 Acute Migraine Medications Based on 10 Million Users’ Self-Reported Records From a Smartphone Application.

For another more detailed analysis, check out Certain Migraine Medications May Be More Effective Than Ibuprofen.

Falling from Favour: Paracetamol / Acetaminophen

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The story of acetaminophen/paracetamol, commonly associated with the brand name Tylenol, is a strange one. A researcher studying treatments for worms requested one chemical and received the wrong one. The worms didn’t mind it, but it did seem to fight fever.

test tubes

It was in the late 1800s that acetaminophen was first used to fight fever and pain in Germany. But it was never widely used until it came to market in the USA and the United Kingdom in the 1950s.

As might be expected, a drug to treat pain and/or fever quickly became popular. Not only by itself, but in combination with other medications under numerous brand names. Few medications are taken with as much frequency as this one.

As is the case with many drugs, we’re not really sure how it works. The most common theory today is that it blocks COX (cyclooxygenase) enzymes in the brain, thus keeping pain signals from being transmitted. Read more from Tufts University School of Medicine: How Does Acetaminophen Work?

Being so common, problems started to arise with overdoses. It’s easy to take too much, or to take two products that contain paracetamol without carefully checking the labels. (By the way, unlike some “painkillers”, taking more of this one doesn’t increase its power – so never take more than the recommended amount thinking it will help you more.)

Liver damage, or even liver failure, from paracetamol is very common. Concerned, the FDA changed its recommendations in 2014. (See also How to Protect Your Liver from Acetaminophen) Added to that have come concerns about hypertension.

The European Journal of Pain published an article entitled “A history of errors, failures and false decisions”, calling it “probably one of the most dangerous compounds in medical use”.

When we thought that taking some during pregnancy was one of the safer options, concerns began to emerge regarding the development of the baby – in particular, “neurodevelopmental, reproductive and urogenital disorders”, and that paracetamol “interferes with sex and thyroid hormone function essential for normal brain development”. Also see Acetaminophen / Paracetamol – Not safe during Pregnancy after all? It seems like there have been a lot of assumptions about this medication’s safety, but not as many studies as such a ubiquitous drug deserves.

The “good” news may be that this may not be your best choice for headaches after all. Sure, if it works for the occasional tension-type headache, there may be no reason to change. But if you’re popping a pill every month, or every week, it’s time to talk to your doctor. But when it comes to other headache conditions such as migraine, there are so many better options that you may want to avoid acetaminophen altogether. See Is Acetaminophen/Paracetamol Really “Ineffective”?

Recent studies remind us of some key issues that we’ve talked about before:

  • Even “safe” medications should be used rarely, if possible. They all have risks.
  • You are an individual, and you need to find what works for you.
  • Lifestyle, such as regular movement and what you eat, are still king, and can never be replaced by a pill.
  • Read labels.
  • Getting headaches on a regular basis? Talk to a specialist. There are probably better treatments than over-the-counter painkillers.

Paracetamol is a unique drug with a strange history. It has helped many, but as our knowledge continues to expand, we may find that it has had its day. This will be an interesting story to keep watching.

Is Acetaminophen/Paracetamol Really “Ineffective”?

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A recent headline says: “Paracetamol ineffective for most pain conditions“. So what’s the story when it comes to headache?

Is acetaminophen really effective for headache?

Paracetamol, also called acetaminophen, is still often known by the common brand name Tylenol. Along with aspirin and ibuprofen, it has been a well-known go-to when it comes to over-the-counter drugs for pain management.

The study (link below) was actually a review of 36 systematic reviews published in medical journals. In those reviews, 44 pain conditions were treated with acetaminophen/paracetamol.

Now, things start to get complicated once you drill down that far. Researchers had to watch for bias or errors in studies, or studies that weren’t relevant for whatever reason. And sometimes you end up with a small amount of information for certain conditions. But you do end up with a good summary of what we know, even if what we know is somewhat limited in certain cases. Make sense? 🙂

The study was also mainly focused on whether or not there was “immediate” pain relief, although a couple of conditions did focus on ongoing treatment (osteoarthritis pain and rheumatoid arthritis).

The good news for headache sufferers is that Tylenol for tension-type headache actually turned out to be one of the more successful stories – although, not that successful. Only two conditions made it to “high quality” evidence, but tension-type headache was listed under “moderate quality evidence of efficacy”. In other words, there is fair evidence that acetaminophen/paracetamol will provide some pain relief for that headache. Not exactly a miracle-cure, according to these researchers.

But notice that I only mentioned tension-type headache. What other headaches made the list?

Quite a few – but acetaminophen/paracetamol only had “low quality evidence” for these headaches:

  • Acute Migraine
  • Cold related headache

There was also low-quality evidence that it wasn’t effective for:

  • Migraine in children/adolescents

Of course there are many other headache types, but generally the evidence wasn’t available either way.

In the end, this study mostly tells us that surprisingly there are very few good quality studies of acetaminophen for headache conditions, and that most of the studies out there simply aren’t all that impressive, with the possible exception of tension-type headache. For other conditions, pain relief after surgery did not fare well, and the condition that really did not seem to be helped at all was lower back pain.

There was good news for craniotomy – surgeries in which the skull is opened up, and knee or hip osteoarthritis. However, researchers admitted that “the effect sizes were very small”.

The other good news is that the number of adverse effects was small – but again researchers noted that there wasn’t very much research to be sure.

It might surprise us that such a ubiquitous top-selling pain killer has so little research behind it. Of course, it’s a challenge to research a “pain killer” for every individual condition. If it kills pain, doesn’t it just pain?

Apparently not. And that’s another interesting point in this study. How well it works, and even adverse effects, depend very much on the condition.

—-> From what we know, if you take acetaminophen/paracetamol very occasionally for headache, and it works for you, no worries. But if headache is a significant disruption in your life, say every month or every week, you should be talking to a doctor to find better options. If that pain killer you’re using really isn’t making your life that much better, it’s time to realize that there are many more options out there.

To read the study, published in the Medical Journal of Australia, just click here: The efficacy and safety of paracetamol for pain relief: an overview of systematic reviews

Drug use in Sports: The Dangers of “Legal Painkillers”

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Athletes are in significant danger of over using over the counter “painkillers”, endangering not only their careers in sport but also their future in general.

Pain in sportFriends and family of athletes, whether athletes on the high school football team or athletes at the Olympics, need to be aware of the incredible pressure that athletes are under to take over the counter drugs such as ibuprofen, naproxen, and paracetamol / acetaminophen, and many stronger versions. We’re not talking about powerful banned performance enhancing drugs here, but the danger is still real.

Many in sport are now coming out in the open to talk about the destructive results of taking so many pills and injections. Overuse of these medications can, in the end, actually keep you from healing properly. Kidney problems, bowel diseases (which can lead to cancer), chronic headache, cardio-vascular problems, and general dependence are only a few of the possible consequences. Many athletes end up in serious depression.

Why would an athlete end up taking a painkiller every single week – maybe even several times a day, in spite of these serious risks? There are a number of reasons:

  • Athletes often have to perform when they have an injury. Headaches from concussion, a twisted ankle – missing a game or “under-performing” can have significant consequences to their career.
  • There are a lot of “normal” aches and pains in most sports. Again, to improve performance, athletes may be tempted to take painkillers before/after the event.
  • Some painkillers may actually improve performance in general. In a world where the perception is that your competitor may be/probably is taking illegal drugs, taking some “legal” drugs feels like an easy way to close the gap a bit.
  • In some circles, taking these medications is not only accepted, but treated as a joke, or even a competition in itself. Athletes may be pressured by other players and even coaches.

As you might imagine, it’s very easy to fall into the trap of taking these over the counter drugs constantly.

For those who care about athletes, be sure to talk about this issue and watch for signs of depression.

For athletes themselves, you need to ask yourself:

  • Do you have to take drugs before and/or after every competition? How long has this been going on?
  • Do you need to take something just to get going in the morning, or to calm down at night?
  • Do you have to take something every week, or even every day?

It’s sad that sports, that should be about being healthy and at your best, continually seems to pressure athletes to abuse their bodies for short term gain. And this is not a matter of an athlete just trying to take fewer pills or injections. It’s a complex, serious issue that requires serious thought be leadership in the field of sports, from doctors who treat athletes, and especially from the family and friends of the athletes. Society needs to be aware of the dangers of this kind of drug use.

If you have become dependant on painkillers or other drugs/alcohol, there is help available. Search online for treatment in your area, talk to your doctor, or people in your community, church, or even family and friends who may have recommendations.

The BBC has been doing some reporting in this area – here are some places to go for more information:

The Best Medication for Migraine? The AHS Reports

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Last month the American Headache Society came out with a new report suggesting which drugs have the best evidence behind them when it comes to migraine. According to the trials, what works the best?

Best Meds 2015This, of course, does not mean that these medications will work the best for you. There is a lot of variation within migraine, and your doctor will help you decide where to start.

However, if your doctor isn’t talking about some of the treatments at the top of the list, you should be asking some questions.

The full report can be found here: The Acute Treatment of Migraine in Adults: The American Headache Society Evidence Assessment of Migraine Pharmacotherapies. However, here is a summary of some of the authors’ findings.

The medications with the best evidence behind them included:

  • The Triptans: Certain specific triptan medications were mentioned, such as almotriptan, sumatriptan, and naratriptan
  • Butorphanol nasal spray
  • NSAIDs: aspirin, diclofenac, ibuprofen and naproxen
  • Acetaminophen, but only for “non-incapacitating attacks”
  • DHE
  • Acetaminophen/aspirin/caffeine combo
  • Sumatriptan/naproxen combo

Some of the medications that really don’t have good evidence behind them, or the evidence is conflicting at this time, include:

  • Lidocaine IV
  • Celecoxib
  • Hydrocortisone IV

This is only a portion of the list – most medications fall between these two extremes. Also, it’s important to note that the researchers noted actual dosages, which means of course that any particular medication may work better/worse at a different dosage, but it may not have been studied.

Also, remember that these are only “acute” medications – taken at the time of an attack – not preventatives.

The conclusion of the study offers an appropriate warning:

According to this systematic review of the literature and structured grading of the evidence strength, specific medications within the following classes are considered “effective” for the acute therapy of migraine: triptans, ergotamine derivatives, NSAIDs, opioids, and combination medications. Several other medications are considered “probably effective” or “possibly effective.” This evidence base for medication efficacy should be considered along with potential medication side effects, potential adverse events, patient-specific contraindications to use of a particular medication, and drug-to-drug interactions when deciding which medication to prescribe for acute therapy of a migraine attack.

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The articles on Headache and Migraine News are © 2004-2024 J. Cottrill.
Every effort is made to ensure the accuracy of each article, and to point you to further sources of information. However, this site is for informational purposes only and should never replace a visit to your doctor.