In the Acute Management of Migraine, Select Triptans Remain Most Efficacious

Compared with recently marketed and more expensive drugs, triptans (ie, eletriptan, rizatriptan, sumatriptan, and zolmitriptan) were more efficacious and tolerable and demonstrated the best overall performance for the acute treatment of migraine, according to study findings published in The BMJ.

Researchers conducted a systematic review and network meta-analysis to compare licensed oral drugs for the acute treatment of migraine episodes in adults. Databases were searched through June 2023 for published and unpublished double-blind randomized controlled trials comparing oral drugs as monotherapy with placebo or another accepted active treatment for the acute treatment of adult outpatients with a migraine diagnosis per the International Classification of Headache Disorders. The primary outcomes were the proportion of patients who experienced no pain at 2 hours post- dose and the proportion of patients who remained pain-free from 2 to 24 hours post-dose. Random effects network meta-analyses were performed and Vitruvian plots were used to summarize findings.

A total of 137 trials were included in the analyses, comprising 62,682 participants who received treatment and 26,763 participants who received placebo. The 17 interventions were classified as antipyretics, ditans, gepants, nonsteroidal anti-inflammatory drugs (NSAIDs), and triptans.

All active interventions vs placebo were more efficacious for pain freedom at 2 hours post-dose (odds ratio [OR], 1.73; 95% CI, 1.27-2.34 for naratriptan to OR, 5.19; 95% CI, 4.25-6.33 for eletriptan).

Most active interventions vs placebo were more efficacious for sustained pain freedom from 2 to 24 hours post-dose, aside from paracetamol (OR, 1.66; 95% CI, 0.68-4.04) and naratriptan (OR, 1.57; 95% CI, 0.76-3.25).

When comparing the active interventions to one another, eletriptan was most efficacious in achieving pain freedom at 2 hours (OR, 1.46; 95% CI, 1.18-1.81 to OR, 3.01; 95% CI, 2.13-4.25) followed by:

• Rizatriptan (OR, 1.59; 95% CI, 1.18-2.17 to OR, 2.44; 95% CI, 1.75-3.45);
• Sumatriptan (OR, 1.35; 95% CI, 1.03-1.75 to OR, 2.04; 95% CI, 1.49-2.86); and,
• Zolmitriptan (OR, 1.47; 95% CI, 1.04-2.08 to OR, 1.96; 95% CI, 1.39-2.86).

Eletriptan (OR, 1.41; 95% CI, 1.02-1.93 to OR, 2.73; 95% CI, 1.35-5.52) and ibuprofen (OR, 3.16; 95% CI, 1.04-9.64 to OR, 4.82; 95% CI, 1.31-17.67) were the most efficacious interventions in terms of sustained pain freedom.

Limitations of this study include the low and very low confidence levels in findings, absence of individual patient data, exclusion of combination drugs, and inability to consider type of oral formulation, consistency in response across migraine episodes, or cost effectiveness.

“Triptans are currently widely underused, and access to the most effective triptans

should be promoted globally and international guidelines updated accordingly,” the study authors concluded.

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.