Article Impact Level: HIGH Data Quality: STRONG Summary of BMJ, 386, e080107. https://doi.org/10.1136/bmj-2024-080107 William K. Karlsson et al.
Points
- This systematic review and network meta-analysis compared 17 oral monotherapies for treating acute migraines using data from 137 randomized controlled trials with 89,445 participants.
- Eletriptan was the most effective drug for achieving pain freedom two hours after the dose, followed by rizatriptan, sumatriptan, and zolmitriptan.
- Eletriptan and ibuprofen were the most effective for sustained pain freedom over 24 hours, with eletriptan showing significant efficacy.
- Most active interventions outperformed placebo, while newer drugs like lasmiditan, rimegepant, and ubrogepant were less effective than triptans.
- The study suggests that triptans like eletriptan should be included in the WHO List of Essential Medicines to improve global access to migraine treatment.
Summary
This systematic review and network meta-analysis compared the efficacy of 17 licensed oral monotherapy treatments for acute migraine episodes in adults. The study analyzed data from 137 randomized controlled trials involving 89,445 participants. The primary outcomes were the proportion of participants who were pain-free at two hours post-dose and sustained pain-freedom from two to 24 hours, both without the use of rescue drugs. Eletriptan was found to be the most effective for pain freedom at two hours (odds ratio [OR]: 5.19, 95% confidence interval [CI]: 4.25 to 6.33), followed by rizatriptan, sumatriptan, and zolmitriptan, all of which significantly outperformed placebo and other comparators.
Regarding sustained pain freedom over 24 hours, eletriptan and ibuprofen were the most efficacious, with eletriptan having an OR of up to 4.82 (95% CI: 1.31 to 17.67). Most active interventions demonstrated superior efficacy compared to placebo, and the findings were consistent across sensitivity analyses, including different doses and risk of bias assessments. Notably, newer drugs like lasmiditan, rimegepant, and ubrogepant were less effective than the established triptans.
The results suggest that eletriptan, rizatriptan, sumatriptan, and zolmitriptan should be preferred for acute migraines. Although further cost-effectiveness analyses are necessary, these triptans should be included in the WHO List of Essential Medicines to improve global accessibility and ensure consistent care standards, particularly for patients without contraindications related to cardiovascular risk.
Link to the article: https://www.bmj.com/content/386/bmj-2024-080107
References Karlsson, W. K., Ostinelli, E. G., Zhuang, Z. A., Kokoti, L., Christensen, R. H., Al-Khazali, H. M., Deligianni, C. I., Tomlinson, A., Ashina, H., Torre, E. R. de la, Diener, H.-C., Cipriani, A., & Ashina, M. (2024). Comparative effects of drug interventions for the acute management of migraine episodes in adults: Systematic review and network meta-analysis. BMJ, 386, e080107. https://doi.org/10.1136/bmj-2024-080107
