The researchers evaluated the effectiveness of 17 migraine medications.
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A comprehensive review of clinical trials suggests that a less commonly used class of medication appears to be more effective at managing migraine-related symptoms than newer, more expensive medications.
Although triptans were specifically developed to treat migraines, they are used in less than 22% of migraine cases. The findings suggest that, unless there is a medical condition that precludes their use, such as cardiovascular disease, low-cost triptans should be considered as a first-line treatment for migraine headaches, says Andrea Cipriani of the University of Oxford.
“It wouldn’t be a bad idea to put all the data together and reiterate to GPs, in particular, that the evidence for using triptans is very good when patients present with migraine, have no contraindications and have tried[non-steroidal anti-inflammatory drugs]before,” says Peter Goadsby of King’s College London, who was not involved in the review.
Triptans, such as sumatriptan and eletriptan, have been gradually approved worldwide since 1991 and are now available as off-brand or generic tablets. However, case reports suggest that these drugs may cause heart attacks and strokes, especially in people with existing cardiovascular disease.
To provide alternative treatments, pharmaceutical companies have developed new drugs called triptans and gepants that have a similar mechanism of action to the triptans but avoid the cardiovascular risks. These drugs (lasmiditan, rimegepant, and ubrogepant) have only been approved in the last few years and are expensive. For example, Eli Lilly’s trademarked formulation of lasmiditan, Raybo, sells for $92.50 per 24-hour tablet, while generic eletriptan costs about $17 per tablet.
Another option is to take painkillers such as nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or paracetamol to help manage migraine symptoms.
Researchers have conducted hundreds of studies investigating the effectiveness, safety, and side effects of each of the many drugs and drug classes used to treat migraines, but studies comparing them with each other have been lacking, Cipriani says. To tap into the wealth of existing knowledge, he and his colleagues analyzed 137 double-blind, randomized, controlled trials conducted around the world since 1991.
The study, which involved a total of 89,445 adults, evaluated the effectiveness of 17 oral medications compared with a placebo or other medications. The research team used criteria recommended by the International Headache Society to evaluate the medications’ efficacy, including how well the medications managed pain over the course of two or 24 hours after a typical dose.
The results showed that the most effective analgesic at two hours was the triptan eletriptan, followed by three triptans: rizatriptan, sumatriptan, and zolmitriptan.
Eletriptan and ibuprofen were the most effective drugs for sustained pain relief for up to 24 hours.
But lasmiditan, rimegepant and ubrogepant were less effective than paracetamol or most NSAIDs in reducing clinical symptoms of migraine and carried a higher risk of side effects such as nausea, so they should be considered as a “third-line” treatment, Cipriani said.
The findings suggest that treating migraines with certain triptans can be effective for some people. But that doesn’t mean it’s the right solution for everyone, adds co-author Elena Ruiz de la Torre of the European Migraine and Headache Alliance in Brussels. “Migraine is a very individual illness,” she says.
“You have to do what’s best for the person sitting in front of you,” Goadsby says. Meta-analyses like this one don’t offer much insight at the individual level, he says: “Meta-analyses can tell you about populations, but they’re a very blunt instrument for trying to understand what’s going on at the individual level.”
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