Triptans in the Acute Treatment of Migraine
Background.—Although triptans are widely used in the acute management of migraine, there is uncertainty around the comparative efficacy of triptans among each other and vs non-triptan migraine treatments. We conducted systematic reviews and network meta-analyses to compare the relative efficacy of triptans (alone or in combination with other drugs) for acute treatment of migraines compared with other triptan agents, non-steroidal anti-inflammatory drugs (NSAIDs), acetylsalicylic acid (ASA), acetaminophen, ergots, opioids, or anti-emetics.
Methods.—The Cochrane Library, MEDLINE, and EMBASE were searched for randomized controlled trials that compared triptans (alone or in combination with other drugs) with placebo-controlled or active migraine treatments. Study selection, data extraction, and quality assessment were completed independently by multiple reviewers. Outcome data were combined and analyzed using a Bayesian network meta-analysis. For each outcome, odds ratios, relative risks, and absolute probability of response were calculated.
Results.—A total of 133 randomized controlled trials met the inclusion criteria. Standard dose triptans relieved headaches within 2 hours in 42 to 76% of patients, and 2-hour sustained freedom from pain was achieved for 18 to 50% of patients. Standard dose triptans provided sustained headache relief at 24 hours in 29 to 50% of patients, and sustained freedom from pain in 18 to 33% of patients. Use of rescue medications ranged from 20 to 34%. For 2-hour headache relief, standard dose triptan achieved better outcomes (42 to 76% response) than ergots (38%); equal or better outcomes than NSAIDs, ASA, and acetaminophen (46 to 52%); and equal or slightly worse outcomes than combination therapy (62 to 80%). Among individual triptans, sumatriptan subcutaneous injection, rizatriptan ODT, zolmitriptan ODT, and eletriptan tablets were associated with the most favorable outcomes.
Interpretation/Conclusions.—Triptans are effective for migraine relief. Standard dose triptans are associated with better outcomes than ergots, and most triptans are associated with equal or better outcomes compared with NSAIDs, ASA, and acetaminophen. Use of triptans in combination with ASA or acetaminophen, or using alternative modes of administration such as injectables, may be associated with slightly better outcomes than standard dose triptan tablets.
Migraine is a common and potentially disabling neurological condition characterized by recurrent moderate to severe pain generally occurring on one side of the head. Globally, it is estimated that over 10 to 15 percent of people suffer from migraines. The condition causes short- and long-term disability, reduces quality of life, and often impacts work productivity, social relationships, and family life.
The acute management of migraines includes the use of non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, ergots, opioids, and triptans. For many patients with moderate to severe migraine, triptans are considered the first-line therapy. There are now seven triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan) available in Canada. The relative efficacy of each triptan among each other is uncertain since the majority of triptan studies have been placebo controlled. Further, while other reviews have attempted to examine the relative efficacy of triptans among each other and vs non-triptan migraine treatments, these studies have not considered multiple routes of administration (tablets, oral disintegrating tablets, injection, nasal spray, rectal suppositories), combination triptan therapy, or dose.
Therefore, as part of a larger initiative by the Ontario Drug Policy Research Network to evaluate triptans for the acute treatment of migraine in adults and provide recommendations for funding changes of these drugs in Ontario (http://odprn.ca/drug-class-review/completed-reviews/triptans/), we conducted a systematic review and network meta-analysis to address the following research question: What is the evidence for the efficacy, effectiveness, and safety of triptans (alone or in combination with other drugs) for acute treatment of migraines compared with: other triptan agents, NSAIDs, acetylsalicylic acid (ASA), acetaminophen, ergots, opioids, or anti-emetics?
Abstract and Introduction
Abstract
Background.—Although triptans are widely used in the acute management of migraine, there is uncertainty around the comparative efficacy of triptans among each other and vs non-triptan migraine treatments. We conducted systematic reviews and network meta-analyses to compare the relative efficacy of triptans (alone or in combination with other drugs) for acute treatment of migraines compared with other triptan agents, non-steroidal anti-inflammatory drugs (NSAIDs), acetylsalicylic acid (ASA), acetaminophen, ergots, opioids, or anti-emetics.
Methods.—The Cochrane Library, MEDLINE, and EMBASE were searched for randomized controlled trials that compared triptans (alone or in combination with other drugs) with placebo-controlled or active migraine treatments. Study selection, data extraction, and quality assessment were completed independently by multiple reviewers. Outcome data were combined and analyzed using a Bayesian network meta-analysis. For each outcome, odds ratios, relative risks, and absolute probability of response were calculated.
Results.—A total of 133 randomized controlled trials met the inclusion criteria. Standard dose triptans relieved headaches within 2 hours in 42 to 76% of patients, and 2-hour sustained freedom from pain was achieved for 18 to 50% of patients. Standard dose triptans provided sustained headache relief at 24 hours in 29 to 50% of patients, and sustained freedom from pain in 18 to 33% of patients. Use of rescue medications ranged from 20 to 34%. For 2-hour headache relief, standard dose triptan achieved better outcomes (42 to 76% response) than ergots (38%); equal or better outcomes than NSAIDs, ASA, and acetaminophen (46 to 52%); and equal or slightly worse outcomes than combination therapy (62 to 80%). Among individual triptans, sumatriptan subcutaneous injection, rizatriptan ODT, zolmitriptan ODT, and eletriptan tablets were associated with the most favorable outcomes.
Interpretation/Conclusions.—Triptans are effective for migraine relief. Standard dose triptans are associated with better outcomes than ergots, and most triptans are associated with equal or better outcomes compared with NSAIDs, ASA, and acetaminophen. Use of triptans in combination with ASA or acetaminophen, or using alternative modes of administration such as injectables, may be associated with slightly better outcomes than standard dose triptan tablets.
Introduction
Migraine is a common and potentially disabling neurological condition characterized by recurrent moderate to severe pain generally occurring on one side of the head. Globally, it is estimated that over 10 to 15 percent of people suffer from migraines. The condition causes short- and long-term disability, reduces quality of life, and often impacts work productivity, social relationships, and family life.
The acute management of migraines includes the use of non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, ergots, opioids, and triptans. For many patients with moderate to severe migraine, triptans are considered the first-line therapy. There are now seven triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan) available in Canada. The relative efficacy of each triptan among each other is uncertain since the majority of triptan studies have been placebo controlled. Further, while other reviews have attempted to examine the relative efficacy of triptans among each other and vs non-triptan migraine treatments, these studies have not considered multiple routes of administration (tablets, oral disintegrating tablets, injection, nasal spray, rectal suppositories), combination triptan therapy, or dose.
Therefore, as part of a larger initiative by the Ontario Drug Policy Research Network to evaluate triptans for the acute treatment of migraine in adults and provide recommendations for funding changes of these drugs in Ontario (http://odprn.ca/drug-class-review/completed-reviews/triptans/), we conducted a systematic review and network meta-analysis to address the following research question: What is the evidence for the efficacy, effectiveness, and safety of triptans (alone or in combination with other drugs) for acute treatment of migraines compared with: other triptan agents, NSAIDs, acetylsalicylic acid (ASA), acetaminophen, ergots, opioids, or anti-emetics?
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