Oral drugs for acute migraines compared head to head

Eletriptan, rizatriptan, sumatriptan, and zolmitriptan had the best profiles as oral monotherapy for acute migraines in adults, a study found.

To compare all licensed migraine drugs, researchers performed a systematic review and network meta-analysis through June 2023. A total of 137 double-blind, randomized controlled trials included 89,445 adults with migraines who were allocated to one of 17 active interventions or placebo. Primary outcomes were the proportion who were pain-free two hours after taking drugs and the proportion with sustained pain relief from two to 24 hours later without the use of rescue drugs. Results were published Sept. 18 by The BMJ.

All active interventions showed superior efficacy to placebo for pain relief at two hours, with odds ratios (ORs) ranging from 1.73 (95% CI), 1.27 to 2.34) for naratriptan to 5.19 (95% CI, 4.25 to 6.33) for eletriptan. Most also had better efficacy for sustained pain relief to 24 hours than placebo, with ORs ranging from 1.71 (95% CI, 1.07 to 2.74) for celecoxib to 7.58 (95% CI, 2.58 to 22.27) for ibuprofen.

In head-to-head comparisons, eletriptan was the most effective drug at two hours (ORs ranging from 1.46 to 3.01), followed by rizatriptan (ORs, 1.59 to 2.44), sumatriptan (ORs, 1.35 to 2.04), and zolmitriptan (ORs, 1.47 to 1.96). For sustained pain relief, the most efficacious interventions were eletriptan and ibuprofen (ORs, 1.41 to 4.82). They were more efficacious than the recently approved drugs lasmiditan, rimegepant, and ubrogepant, researchers wrote.

Although cost-effectiveness analyses are needed and careful consideration should be given to patients with a high-risk cardiovascular profile, the most effective triptans should be considered as preferred acute treatment for migraine, the study authors said. New migraine drugs have expanded options for the acute treatment of migraine, but their high costs and the substantial adverse effects of lasmiditan suggest their use as third-line options, after the less expensive, similarly efficacious, second-line options such as ibuprofen, acetylsalicylic acid, diclofenac potassium, almotriptan, and frovatriptan, the authors wrote.

“The inclusion of the most effective triptans (available as generic drugs) into the WHO Model List of Essential Medicines should be considered to promote global accessibility and uniform standards of care (currently, sumatriptan is the only triptan included),” they said. “Limited access to triptans and their substantial underutilisation represents missed opportunities to offer more effective treatments and deliver better quality of care to people who experience migraine.”