NSAIDs first line for mild /moderate migraine
NSAIDs such as ibuprofen are among the first-line treatments for acute mild to moderate migraine, according to new guidelines published in the UK (Curr Med Res Opin 2002;18:414-39; www.medscape.com/viewarticle/446557)
and reported by the International Ibuprofen Foundation.

Compiled by UK specialists and general practitioners, the guidelines provide a rational and pragmatic approach to the management of migraine in primary care, the Foundation reports.

The aim of treating acute migraine is to relieve headache and associated symptoms and allow the patient to return to normal life. Recommended initial treatments for mild to moderate migraine are high-dose NSAIDs such as ibuprofen or aspirin and combinations of analgesics with antiemetics or isometheptene. In more severe cases, a 5HT1 agonist - or triptan - should be the first choice.

There is no evidence that paracetamol alone is effective, the guidelines say, and in general opiates should be avoided.
Danes find no link between NSAIDs and peptic ulcer.

The safety of ibuprofen is once again emphasised, according to the International Ibuprofen Foundation, in a new study from
Denmark which claims that NSAIDs are not a significant risk factor for developing peptic ulcer, or gastric ulcer in particular (Gut 2003;52:186-93).

2416 randomly selected adults with no history of peptic ulcer disease were questioned about potential risk factors in 1982 and again in 1994. During the 11-year interval, 71 (2.9%) had
developed a duodenal or gastric ulcer for the first time.

The baseline characteristics that were statistically associated with developing either type of ulcer were: Helicobacter pylori infection (odds ratio 4.3), tobacco smoking (OR 3.0 - 4.5), and current use of anxiolytics (OR 3.2) or gastrointestinal medication such as an H2 antagonist (OR 3.2). All those who developed a duodenal ulcer were either former or current smokers and smoking accounted for 60% of total ulcer risk.

Furthermore, drinking spirits increased ulcer risk, and modest
exercise reduced it, in those with H pylori infection.

Surprisingly, use of NSAIDs was not significantly associated with peptic ulcer, or with gastric ulcer, with odds ratios of 0.8 (CI95% 0.3, 2.3) for previous use and 0.4 (CI95% 0.1, 2.3) for current use. The authors acknowledge that their findings go against accepted wisdom.

Possible explanations for the disparity include low statistical power due to too few first-time gastric ulcers, few complicated ulcers, relatively few vulnerable participants (aged over 70), and failing to collect adequate data on NSAID use. Overall, they
concluded, the aetiology of peptic ulcer is multifactorial and the biggest contributory factors in Denmark are smoking, use of anxiolytics and H pylori infection.

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