Zolmitriptan versus a combination of acetylsalicylic acid and metoclopramide in the acute oral treatment of migraine: a double‐blind, randomised, three‐attack study.
Authors: Geraud G , Compagnon A , Rossi A 
Published: December 2004

Eur Neurol. 2002;47(2):88‐98

This multicentre, randomised, double‐blind study compared oral zolmitriptan 2.5 mg with a combination of oral acetylsalicylic acid 900 mg and metoclopramide 10 mg as acute anti‐migraine therapy for 3 migraine attacks. In total, 666 patients took at least one dose of study medication (326 took zolmitriptan and 340 took acetylsalicylic acid plus metoclopramide). The percentage of patients with a 2‐hour headache response after the first dose for all 3 attacks (the primary end point) was 33.4% with zolmitriptan and 32.9% with acetylsalicylic acid plus metoclopramide [odds ratio 1.06, 95% confidence interval (CI) 0.77‐1.47; p  =  0.7228]. For the majority of secondary end points, the two treatments demonstrated comparable efficacy. However, post hoc analysis showed that significantly more patients receiving zolmitriptan were free of pain 2 h after the first dose in all 3 attacks compared with patients receiving acetylsalicylic acid plus metoclopramide (10.7 vs. 5.3%; odds ratio 2.19, 95% CI 1.23‐4.03; p  =  0.0095). In addition, post hoc analysis showed that the overall 2‐hour pain‐free response rate was consistently higher with zolmitriptan (34.6%) than with acetylsalicylic acid plus metoclopramide (27.9%) (odds ratio 1.40, 95% CI 1.09‐1.78; p  =  0.007). Both treatments reduced migraine‐associated nausea, vomiting, phonophobia and photophobia. There were no important inter‐group differences with respect to the onset of meaningful migraine relief, the frequency of headache recurrence, the usage or efficacy of a second dose of medication or the use of escape medication. However, at the last attack, the proportion of patients who expressed overall satisfaction with the treatment was significantly higher in the zolmitriptan group, i.e. 83.7%, versus 75.0% with acetylsalicylic acid plus metoclopramide (p  =  0.0346). Both agents were well tolerated. Adverse events were reported by 40.8% (133/326) of zolmitriptan‐treated patients and 29.1% (99/340) of those treated with acetylsalicylic acid plus metoclopramide. The incidence of withdrawals due to adverse events was very low with both zolmitriptan (0.9%) and the combination regimen (1.5%); the latter percentage included 1 patient who withdrew from the study due to phlebitis, which was classified as a serious adverse event. This study showed that zolmitriptan is effective and well tolerated for the acute treatment of moderate to severe migraine. Zolmitriptan was at least as effective as acetylsalicylic acid plus metoclopramide in achieving a 2‐hour headache response, but significantly more effective than the combination therapy for other end points, including the 2‐hour pain‐free response.

Comment: As the global project physician for zolmitriptan (1976‐1978), I was personally involved in designing this study, which surprisingly did not show greater efficacy for zolmitriptan when compared to high‐dose aspirin‐metoclopramide. However, as pointed out by Stew Tepper above, this pattern has been described with the other triptans and only when compared against pain‐free and sustained pain‐free responses do the triptans deliver the goods. This study also raises symmetry issues in the comparison groups regarding previous baseline treatments. In this study, the majority of patients had previously successfully used the aspirin‐metoclopramide product, whereas triptan users were in the minority, due to the lack of availability of triptans for the treatment of migraine in France at this time. DSM