Can aspirin (acetylsalicylic acid) be used to treat migraine headaches in adults?

Can Aspirin Help in Migraine?

Yes, aspirin 900-1000 mg is an effective first-line treatment for acute migraine attacks, with efficacy comparable to sumatriptan 50 mg, and should be taken as early as possible at symptom onset. 1, 2, 3

Evidence-Based Dosing and Administration

For acute migraine treatment:

• Aspirin 650-1000 mg should be taken at the first sign of migraine symptoms 1
• The optimal dose is 900-1000 mg, which provides a 2-hour headache response rate of 52% versus 34% with placebo 2
• Pain relief begins as early as 30 minutes after administration and continues through 6 hours 2, 4
• At 2 hours post-treatment, 20% of patients achieve complete pain freedom with aspirin versus only 6% with placebo 2
• Maximum initial dose is 1000 mg, with a maximum daily dosage of 4000 mg 1

Combination Therapy for Enhanced Efficacy

Adding metoclopramide 10 mg to aspirin significantly improves outcomes, particularly for nausea and vomiting:

• The combination provides superior relief of migraine-associated nausea (P < 0.00006) and vomiting (P = 0.002) compared to aspirin alone 3
• Metoclopramide should be taken 20-30 minutes before aspirin to enhance gastric motility and improve aspirin absorption 1
• The combination of aspirin plus acetaminophen plus caffeine is recommended for moderate to severe migraine or when NSAIDs alone fail 1

Clinical Positioning in Treatment Algorithm

Aspirin is positioned as first-line therapy for mild to moderate migraine:

• Use aspirin for mild to moderate migraine attacks or severe attacks that have been responsive to similar agents in the past 1
• If aspirin fails after 2-3 migraine episodes, escalate to migraine-specific drugs (triptans) 1
• Aspirin has comparable efficacy to sumatriptan 50 mg for 2-hour pain-free and headache relief outcomes 3
• Aspirin is more cost-effective than prescription triptans while maintaining similar efficacy 5

Critical Frequency Limitation to Prevent Medication-Overuse Headache

Limit aspirin use to no more than 2 days per week (or 15 days per month) to prevent medication-overuse headache:

• Overuse of analgesics leads to rebound headaches and increasing headache frequency 1
• If you need acute treatment more than twice weekly, initiate preventive therapy immediately 6
• Medication-overuse headache can paradoxically worsen migraine frequency and lead to chronic daily headaches 6

Potential Role in Migraine Prevention

Daily low-dose aspirin (81-325 mg) may reduce migraine frequency, though evidence is less robust than for acute treatment:

• Some studies suggest aspirin at doses of at least 325 mg/day can reduce migraine frequency 7
• The optimal preventive dosage remains unclear, with studies showing variable results 7
• Preventive therapy should be considered if you have more than 2 headaches per week 1

Contraindications and Safety Considerations

Aspirin is contraindicated in:

• G6PD deficiency 1
• Active bleeding disorders 1
• Aspirin/NSAID-induced asthma 1

Common adverse effects:

• GI upset is the most common side effect, though adverse events are generally mild and transient 1, 2, 3
• Adverse events occur slightly more frequently with aspirin than placebo but less commonly than with sumatriptan 100 mg 3
• Rectal suppositories may cause local irritation 1

Practical Clinical Pearls

Optimize aspirin effectiveness:

• Administer as early as possible during the attack to improve efficacy 1
• Mouth-dispersible formulations may provide faster absorption and earlier relief (as early as 30 minutes) compared to standard tablets 4
• For migraine accompanied by nausea or vomiting, use a non-oral route of administration or add an antiemetic 1
• Only 34% of aspirin-treated patients need rescue medication at 24 hours compared with 52% of placebo-treated patients 2