CLINICAL QUESTION

What are the comparative benefits of the available treatments for acute migraine pain?

BOTTOM LINE

Adding a triptan (eg, sumatriptan) when a nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen is ineffective will provide good symptom relief for most patients with acute migraine, with only a small risk of adverse effects. (Level of Evidence = 1a)

SYNOPSIS

A research librarian searched three databases, including Cochrane Central, and reference lists of identified studies. Investigators selected articles for inclusion. They augmented their findings with results from previous reviews. They identified 21 head-to-head studies and 165 placebo-controlled studies of treatment of acute migraine in adult outpatients that were published in English. Single reviewers extracted the data, and a second reviewer checked that data. Risk of bias was assessed independently by two reviewers. The reviewers did a pairwise meta-analysis when possible and conducted a network meta-analysis to get a complete picture. Triptan treatment was most effective for pain relief at 2 hours and freedom from pain for up to 48 hours after treatment. The combination of a triptan and NSAID is more effective than the triptan alone; adding acetaminophen to a triptan does not improve pain relief. Treatment with a triptan may be associated with a higher risk of adverse effects, although the risk is low. The analysis found no advantage of the newer ditan and gepant classes of migraine treatments and did not include older treatments such as metoclopramide, ergotamine, and prochlorperazine.