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Three Part Question

in [children and adolescents with known migraine] is [oral ibuprofen better than paracetamol] at [resolving pain]?

Clinical Scenario

A ten year old boy presents to the Emergency Department with a history of a severe throbbing headache which has started one hour ago. He is a known migraine sufferer and has had previous attacks, the last being two weeks ago. After history and clinical examination, you diagnose him with migraine, and decide that over the counter analgesics are the most appropriate. You wonder whether ibuprofen would be better than paracetamol for pain relief.

Search Strategy

Medline 1950-July 2010 using Ovid interface
EMBASE 1980-July 2010 using Ovid interface
Cochrane Database of Systematic Reviews (July 2010)
Medline
[(Exp migraine disorders OR exp Headache OR exp Primary Headache Disorders OR exp Headache Disorders) AND (exp Anti-Inflammatory Agents OR ibuprofen.mp. OR exp Non-Steroidal Anti-Inflammatory Agents) AND (exp Acetaminophen) AND (LIMIT to English language AND Humans) AND (LMIT to “All Child (0-18 years)”)]
EMBASE
[(Exp migraine aura OR exp migraine without aura OR exp migraine with aura OR exp migraine OR exp headache OR exp primary headache) AND (exp Ibuprofen) AND (exp Paracetamol) AND (LIMIT to (Human and English Language) AND (LIMIT to (child OR preschool child <1 to 6 years> OR school child <7 to 12 years> OR adolescent <13 to 17 years>)
Cochrane Database of Systematic Reviews (July 2010)
Search’migraine’ (ti,ab,kw)

Search Outcome

38 papers found in Medline, 1 was relevant.
151 papers found in EMBASE, 1 was relevant.
98 papers found in Cochrane, 1 was relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
M. L. Hamalainen et al 1997 Finland	106 children <18 years fulfilling IHS criteria for migraine, that had been referred to any of three paediatric hospitals. Inclusion criteria; 2 or more headaches per month lasting >2 hours & ability to complete own headache diary. Only 66 children were eligible for data analysis on trial completion.	Randomised Control Trial; double-blind, randomised, three-way crossover study	Pain; rated at 1h and 2 h, using five faces scale or continuous visual analogue scale	1. Alleviation at 2h: ibuprofen 68% paracetamol 54% 2.Complete resolution at 2 h: ibuprofen 60% paracetamol 39%. Both have similar effects, but ibuprofen is overall more effective.	Administration at home, less supervision and control. Use of 2 different scales, may not correlate as well.
L. Billinghurst et al 2009, awaiting review Canada	currently under construction	Intervention Protocol for a review	Objective;To describe and assess the evidence from controlled trials on the efficacy and tolerability of pharmacological interventions by any route of administration versus placebo or other drug treatments for acute attacks of migraine in children	n/a	Results are currently unavailable, but eventually may be relevant to clinical question.
C. A Pierce et al 2010 U.S	85 studies directly comparing ibuprofen and acetaminophen in adults and children. 54 contained analgesic efficacy data.	Meta-analysis and Qualitative Review	pain reduction	ibuprofen better than paracetamol in adults & children	ABSTRACT ONLY. Not entirely relevant to clinical question; is not specific to migraine and the paediatric population exclusively.
			temperature reduction	ibuprofen better than paracetamol in adults & children
			safety	ibuprofen and acetaminophen equally safe in adult & paediatric populations

Comment(s)

Only one paper (Hamalainen et al) is completely relevant to clinical question. The second paper (Pierce et al) provides low quality evidence, but does support the conlcusions made in the first, thus strengthening the available evidence.

Clinical Bottom Line

Ibuprofen is more effective than paracetamol at pain relief for migraine attacks in children

References

1. M. L. Hamalainen, K. Hoppu, E. Valkeila et al Ibuprofen or Acetaminophen for the acute treatment of migraine in children: A double-blind, randomized, placebo-controlled crossover study Neurology 1997; 48:103-107
2. L. Billinghurst, L. Richer, KF Russell et al Drugs for treating acute migraine headaches in children and adolescents (protocol) The Cochrane Collaboration 2009; Issue 1:1-9
3. C. A. Pierce, V. Boss Efficacy and Safety of Ibuprofen and Acetaminophen in Children and Adults: A Meta-Analysis and Qualitative Review The Annals of Pharmacotherapy 2010;44 issue 3:489-506