Implementing AHRQ Effective Health Care Reviews

Helping Clinicians Make Better Treatment Choices

Acute Treatments for Episodic Migraine in Adults

 

Am Fam Physician. 2021 Nov ;104(5):509-512.

Author disclosure: No relevant financial affiliations.

Key Clinical Issue

How effective are pharmacologic and nonpharmacologic acute treatments for episodic migraine in adults?

Evidence-Based Answer

Nonsteroidal anti-inflammatory drugs (NSAIDs) and triptans, individually and combined, are superior compared with placebo in resolving episodic migraine pain and are first-line choices for acute treatment. (Strength of Recommendation [SOR]: A, based on consistent, good-quality patient-oriented evidence.) Acetaminophen and dihydroergotamine also relieve migraine pain better than placebo. (SOR: A, based on consistent, good-quality patient-oriented evidence.) Calcitonin gene-related peptide antagonists and lasmiditan improve pain and function in acute migraines compared with placebo. (SOR: A, based on consistent, good-quality patient-oriented evidence.) Opioids do not improve pain or function, and adverse events are greater, compared with established migraine treatment options. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) Acupuncture does not relieve migraine pain compared with sham acupuncture, but noninvasive vagus nerve stimulation and remote electrical neuromodulation relieve acute migraine pain compared with sham stimulation.1 (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.)

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CLINICAL BOTTOM LINE

Nonopioid Pharmacologic Treatment of Acute Migraine vs. Placebo

Treatment (cost for 10 doses)*Findings (95% CI)Number of studies (participants)Strength of evidence

Triptans ($15)

More pain relief at all time points; NNT < 10 in every systematic review

9 systematic reviews (n = 101,276)

●●●

NSAIDs ($3)

More pain relief at all time points; NNT < 10 in every systematic review

4 systematic reviews (n = 10,272)

●●●

Acetaminophen ($2)

More pain relief at 2 hours; NNT = 12

1 systematic review (n = 2,942)

●●●

More restored function at 2 hours; RR = 1.80 (1.27 to 2.54)

2 RCTs (n = 729)

●●○

No difference in total adverse events

2 RCTs

Dihydroergotamine ($800)

More pain relief at 2 hours; RR = 1.83 (1.58 to 2.13)

3 RCTs (n = 1,299)

●●●

More pain relief at 1 week; RR = 1.48 (1.22 to 1.80)

1 RCTs (n = 903)

●●○

No difference in total adverse events

4 RCTs

Ergotamine plus caffeine ($90)

No difference in function

1 RCT (n = 309)

●○○

More pain relief at 2 hours; RR = 1.61 (1.05 to 2.49)

1 RCT (n = 309)

●●○

No difference in total adverse events

2 RCTs

Chlorpromazine ($20)

No difference in function

1 RCT (n = 36)

●○○

More pain relief at 2 hours; RR = 5.46 (2.97 to 10.05)

2 RCTs (n = 123)

●○○

No difference in total adverse events

1 RCT

Droperidol ($180)

More pain relief at 2 hours; RR = 1.39 (1.11 to 1.74)

1 RCT (n = 305)

●○○

More total adverse events; RR = 1.61 (1.18 to 2.20)

1 RCT

Haloperidol ($9)

More pain relief at 2 hours; RR = 5.33 (1.84 to 15.49)

1 RCT (n = 40)

●○○

More total adverse events; RR = 6 (2.12 to 120.65)

1 RCT

Metoclopramide ($3)

More pain relief at 2 hours; RR = 1.91 (1.47 to 2.48)

3 RCTs (n = 268)

●○○

No difference in total adverse events

2 RCTs

Prochlorperazine ($6)

More pain relief at 2 hours; RR = 1.80 (1.10 to 2.94)

2 RCTs (n = 90)

●○○

More total adverse events; RR = 6.48 (1.49 to 28.17)

1 RCT

Rimegepant ($1,000)

More pain relief at 2 hours; RR = 1.36 (1.26 to 1.46)

3 RCTs (n = 3,336)

●●○

More pain relief at 1 week; RR = 1.64 (1.40 to 1.93)

1 RCT (n = 1,466)

●●○

More restored function at 2 hours; RR = 1.43 (1.26 to 1.62)

2 RCTs (n = 2,652)

●●○

More total adverse events; RR = 1.23 (1.00 to 1.50)

3 RCTs

Ubrogepant ($900)

Improved function at 2 hours; RR = 1.26 (1.12 to 1.42)

2 RCTs (n = 3,358)

●●●

More pain relief at 2 hours; RR = 1.21 (1.12 to 1.31)

3 RCTs (n = 4,192)

●●●

No difference in pain relief at 2 weeks

1 RCT (n = 833)

●○○

No difference in total adverse events

3 RCTs

Lasmiditan ($900)

More pain relief at 2 hours; RR = 1.38 (1.14 to 1.68)

4 RCTs (n = 5,742)

●●●

More restored function at 2 hours; RR = 1.42 (1.26 to 1.61)

2 RCTs (n = 5,100)

●●●

More total adverse events; RR = 2.67 (2.10 to 3.39)

4 RCTs

Dexamethasone ($10)

No difference in restored function at 2 hours

1 RCT (n = 205)

●○○

More restored function at 1 week; RR = 1.49 (1.04 to 2.13)

1 RCT (n = 115)

●○○

No difference in total adverse events

2 RCTs

Lidocaine ($10)

More pain relief at 2 hours; RR = 2.14 (1.16 to 3.96)

2 RCTs (n = 130)

●○○

More total adverse events; RR = 3.30 (1.76 to 6.17)

2 RCTs

Magnesium sulfate ($100)

More pain relief at 2 hours; RR = 3.86 (2.11 to 7.07)

1 RCT and 1 crossover RCT (n = 150)

●○○

Octreotide ($25)

More pain relief at 1 day; RR = 3.06 (1.11 to 8.44)

1 RCT (n = 29)

●○○

No difference in total adverse events

1 RCT


Strength of evidence scale

●●● High: High confidence that the evidence reflects the true effect. Further research is very unlikely

Address correspondence to Tyler Barreto, MD, MPH, at barretotw@gmail.com. Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Halker Singh RB, VanderPluym JH, Morrow AS, et al. Acute treatments for episodic migraine. Comparative effectiveness review no. 239. (Prepared by the Mayo Clinic Evidence-based Practice Center under contract no. 290-2015-00013-I.) AHRQ publication no. 21-EHC009. Agency for Healthcare Research and Quality; December 2020. Accessed March 1, 2021. https://effectivehealthcare.ahrq.gov/sites/default/files/cer-239-acute-migraine-evidence-summary.pdf...

2. Burch R, Rizzoli P, Loder E. The prevalence and impact of migraine and severe headache in the United States: figures and trends from government health studies. Headache. 2018;58(4):496–505.

3. Centers for Disease Control and Prevention. Acute pain. Acute migraine. Accessed April 10, 2021. https://www.cdc.gov/acute-pain/migraine/index.html

4. American Headache Society. The American Headache Society position statement on integrating new migraine treatments into clinical practice [published correction appears in Headache. 2019;59(4):650–651]. Headache. 2019;59(1):1–18.

5. VanderPluym JH, Halker Singh RB, Urtecho M, et al. Acute treatments for episodic migraine in adults: a systematic review and meta-analysis. JAMA. 2021;325(23):2357–2369.

6. Derry CJ, Derry S, Moore RA. Sumatriptan (oral route of administration) for acute migraine attacks in adults. Cochrane Database Syst Rev. 2012;(2):CD008615.

7. Law S, Derry S, Moore RA. Sumatriptan plus naproxen for acute migraine attacks in adults. Cochrane Database Syst Rev. 2013;(10):CD008541.

8. Loder E, Weizenbaum E, Frishberg B, et al.; American Headache Society Choosing Wisely Task Force. Choosing wisely in headache medicine: the American Headache Society's list of five things physicians and patients should question. Headache. 2013;53(10):1651–1659.

9. Mayans L, Walling A. Acute migraine headache: treatment strategies. Am Fam Physician. 2018;97(4):243–251. https://www.aafp.org/afp/2018/0215/p243.html

10. Negro A, Delaruelle Z, Ivanova TA, et al.; European Headache Federation School of Advanced Studies (EHF-SAS). Headache and pregnancy: a systematic review. J Headache Pain. 2017;18(1):106.

11. De novo classification request for gammaCore non-invasive vagus nerve stimulator. October 15, 2015. Accessed April 18, 2021. https://www.accessdata.fda.gov/cdrh_docs/reviews/DEN150048.pdf

12. De novo classification request for nerivio migra. November 6, 2018. Accessed April 18, 2021. https://www.accessdata.fda.gov/cdrh_docs/reviews/DEN180059.pdf

13. Centers for Devices and Radiological Health. Evaluation of automatic class III designation (de novo) summaries. U.S. Food and Drug Administration. April 2021. Accessed April 18, 2021. https://www.fda.gov/about-fda/cdrh-transparency/evaluation-automatic-class-iii-designation-de-novo-summaries

The Agency for Healthcare Research and Quality (AHRQ) conducts the Effective Health Care Program as part of its mission to produce evidence to improve health care and to make sure the evidence is understood and used. A key clinical question based on the AHRQ Effective Health Care Program systematic review of the literature is presented, followed by an evidence-based answer based on the review. AHRQ's summary is accompanied by an interpretation by an AFP author that will help guide clinicians in making treatment decisions. For the full review, go to https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/cer-239-acute-migraine-review.pdf.

This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

A collection of Implementing AHRQ Effective Health Care Reviews published in AFP is available at https://www.aafp.org/afp/ahrq.

 

 

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