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Ibuprofen for acute treatment of episodic tension-type headache in adults


Tags: medications, headache, self-treatment, treatment, head, head/neck, pain problems

Three articles on PainSci cite Derry 2015: (1) Complete Guide to Low Back Pain(2) The Complete Guide to Headaches(3) The Complete Guide to Neck Pain & Cricks

PainSci notes on Derry 2015:

According to this major 2016 review, which included a dozen good quality trials in many hundreds of patients, ibuprofen does seem to work quite well for tension headaches … but only for some people. Only about 1 in 6 people will get a good result compared to a placebo, and you have to give (400mg) ibuprofen to about 14 people to find just one who gets complete headache relief. (This may suggest that inflammation is more relevant to a few headaches than most others.)

This is one of three closely related reviews of medications for episodic tension-type headache (see also Derry 2017 and Stephens 2016). The others, about aspirin and paracetamol (acetaminophen), reported only trivial benefits based on generally poor quality evidence, and are classic GIGO reviews (garbage in, garbage out). Overall, the evidence for common over-the-counter meds for headache is surprisingly shabby, and constitutes a particularly good example of how modern medicine isn’t based on nearly as much settled science as we tend to assume.

original abstract Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

BACKGROUND: Tension-type headache (TTH) affects about one person in five worldwide. It is divided into infrequent episodic TTH (fewer than one headache per month), frequent episodic TTH (1 to 14 headaches per month), and chronic TTH (15 headaches a month or more). Ibuprofen is one of a number of analgesics suggested for acute treatment of headaches in frequent episodic TTH.

OBJECTIVES: To assess the efficacy and safety of oral ibuprofen for treatment of acute episodic TTH in adults.

SEARCH METHODS: We searched CENTRAL (The Cochrane Library), MEDLINE, EMBASE, and our own in-house database to January 2015. We sought unpublished studies by asking personal contacts and searching on-line clinical trial registers and manufacturers' websites.

SELECTION CRITERIA: We included randomised, placebo-controlled studies (parallel-group or cross-over) using oral ibuprofen for symptomatic relief of an acute episode of TTH. Studies had to be prospective and include at least 10 participants per treatment arm.

DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion, and extracted data. Numbers of participants achieving each outcome were used to calculate risk ratio (RR) and number needed to treat for an additional beneficial outcome (NNT) or number needed to treat for an additional harmful outcome (NNH) of oral ibuprofen compared to placebo for a range of outcomes, predominantly those recommended by the International Headache Society (IHS).

MAIN RESULTS: We included 12 studies, all of which enrolled adult participants with frequent episodic TTH. Nine used the IHS diagnostic criteria, but two used the older classification of the Ad Hoc Committee, and one did not describe diagnostic criteria but excluded participants with migraines. While 3094 people with TTH participated in these studies, the numbers available for any form of analysis were lower than this; placebo was taken by 733, standard ibuprofen 200 mg by 127, standard ibuprofen 400 mg by 892, and fast-acting ibuprofen 400 mg by 230. Participants had moderate or severe pain at the start of treatment. Other participants were either in studies not reporting outcomes we could analyse, or were given one of several active comparators in single studies. For the IHS-preferred outcome of being pain free at 2 hours the NNT for ibuprofen 400 mg (all formulations) compared with placebo was 14 (95% confidence interval (CI), 8.4 to 47) in four studies, with no significant difference from placebo at 1 hour (moderate quality evidence). The NNT was 5.9 (4.2 to 9.5) for the global evaluation of 'very good' or 'excellent' in three studies (moderate quality evidence). No study reported the number of participants experiencing no worse than mild pain at 1 or 2 hours. The use of rescue medication was lower with ibuprofen 400 mg than with placebo, with the number needed to treat to prevent one event (NNTp) of 8.9 (5.6 to 21) in two studies (low quality evidence). Adverse events were not different between ibuprofen 400 mg and placebo; RR 1.1 (0.64 to 1.7) (high-quality evidence). No serious adverse events were reported.

AUTHORS' CONCLUSIONS: Ibuprofen 400 mg provides an important benefit in terms of being pain free at 2 hours for a small number of people with frequent episodic tension-type headache who have an acute headache with moderate or severe initial pain. There is no information about the lesser benefit of no worse than mild pain at 2 hours.

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