Four triptans are effective in the acute phase Migraine than newer, more expensive drugs headache A new study suggests that it could be that type.
According to the results of a large systematic review and meta-analysis, Eletriptan, Rizatriptan, SumatriptanZolmitriptan, Lasmiditan, RimegepantThe researchers found that ubrogepant was as effective as nonsteroidal anti-inflammatory drugs (NSAIDs).
International guidelines generally recommend NSAIDs as first-line treatment for migraine, with triptans recommended for moderate to severe attacks or when there is an inadequate response to NSAIDs.
But based on the study’s findings, these four triptans should be considered first-line treatments for migraines, study researcher Andrea Cipriani, MD, professor of psychiatry at the University of Oxford and director of the Oxford Health Clinical Research Facility in Oxford, England, said at a press conference.
The researchers concluded that these particular triptans are [World Health Organization] A list of essential medicines to promote global accessibility and uniform standards of care.
This study Publish online On September 18th of BMJ.
Filling the knowledge gap
To date, most migraine studies have compared migraine medications to a placebo, creating a knowledge gap, Cipriani said. As a result, “there is no clear consensus among experts or guidelines about which specific drug classes should be prescribed first, which creates a clinical problem.”
The researchers noted that in recent years, lasmiditan and gepants have been introduced as further treatment options, especially for patients in whom triptans are contraindicated due to their potential vasoconstrictor effects and increased risk of ischemic events.
The analysis included 137 double-blind randomized controlled trials, primarily sponsored by the pharmaceutical industry, which included 89,445 adult outpatients with migraine (mean age 40.3 years, 85.6% women).
Only drugs that are licensed to treat migraines in at least one country were included. The researchers divided these 17 drugs into five categories: antipyretics (paracetamol), diazepam (lasmiditan), gepant (rimegepant and ubrogepant), NSAIDs (acetylsalicylic acid, Celecoxib, Diclofenac potassium, Ibuprofen, Naproxen sodium, phenazone), triptan (Almotriptaneletriptan, Frovatriptan, Naratriptanrizatriptan, sumatriptan, zolmitriptan).
The primary outcomes of the study were freedom from pain after 2 hours and 2–24 hours without the use of rescue medication.
The researchers used sumatriptan as the reference intervention because it is the most commonly prescribed migraine medication and is included in the WHO Model List of Essential Medicines.
The study showed that all active interventions were superior to placebo in terms of reducing pain at 2 hours. All interventions were superior in providing sustained pain relief from 2 to 24 hours, except for paracetamol and naratriptan.
When comparing active interventions, eletriptan was superior to other drugs in achieving pain relief at 2 hours, followed by rizatriptan, sumatriptan, and zolmitriptan (odds ratio 0.011-0.025). [OR]The most effective interventions for achieving sustained pain freedom through 24 hours were eletriptan (OR, 1.41-2.73) and ibuprofen (OR, 3.16-4.82).
Regarding secondary efficacy outcomes, in head-to-head comparisons, eletriptan was superior to nearly all other active interventions for analgesia and rescue medication use after 2 hours.
Regarding adverse events, dizziness occurred more commonly with lasmiditan, eletriptan, sumatriptan, and zolmitriptan, fatigue and sedation occurred more frequently with eletriptan and lasmiditan, nausea occurred more frequently with lasmiditan, sumatriptan, zolmitriptan, and ubrogepant, and eletriptan was the only intervention most frequently associated with chest pain or discomfort.
Do the guidelines need to be updated?
Cipriani and study co-author Mehsoud Ashina, MD, professor of neurology at the University of Copenhagen in Copenhagen, Denmark, said clinical guidelines for managing acute migraines need to be updated in light of the new results.
Although triptans are contraindicated in patients with vascular disease, the researchers noted that “cerebrovascular events may manifest primarily as migraine-like headaches, and may also include transient ischemic attacks and milder strokes.” stroke Because migraines are not uncommon.”
Recently, the non-vasoconstricting drugs lasmiditan, rimegepant, and ubrogepant have been promoted as alternatives for patients in whom triptans are contraindicated or cannot be tolerated, but the high cost of these drugs makes them out of reach for some patients, the researchers noted.
Triptans are underused, Ashina noted during the press conference: Current usage rates range from 17 to 22 percent in the United States and 3 to 22.5 percent in Europe.
The researchers said triptans have been shown to be superior and should be promoted worldwide, adding that limited availability and significant underutilization of these drugs is a “missed opportunity to provide more effective treatment”.
Cipriani said the new results underscore the importance of gold-standard, head-to-head trials.
The researchers noted that the main limitation of the study was data quality, which was deemed to be of low or very low quality for most comparisons. Other potential limitations include lack of individual patient data, exclusion of concomitant medications, inclusion of oral treatments only, and failure to consider the type of oral formulation, consistency of response across migraine attacks, or cost-effectiveness.
The study also did not address important clinical issues that could inform treatment decisions, such as headaches after drug overdose or potential withdrawal symptoms, and the authors were unable to quantify some outcomes, such as global functioning.
“Best Profile”?
Reached for comment, Nina Liggins, MD, a neurologist at the Palo Alto VA Medical Center Headache Research Center in Palo Alto, California, praised the authors for doing a “great job” in drawing attention to the topic.
However, she noted that she was skeptical of the researchers’ assessment that four triptans had the “best properties” for acute migraine headaches.
“Calling triptans the ‘best-characterized’ drugs may not be true in many cases,” she said. For example, people who have cardiovascular contraindications for triptans, as well as those who require acute dosing more than two or three times a week, may fall outside that category, Riggins noted.
Liggins said it’s “not surprising” that long-acting triptans like frovatriptan and naratriptan don’t get high marks for effectiveness within the first two hours. But she noted that these drugs likely provide better treatment in certain situations, such as menstrual-related migraines.
Additionally, triptans are known to cause medication overuse headaches, but that may not be the case with Gepants, she noted.
In a statement from the Science Media Centre, a non-profit organisation that promotes voices and views from the scientific community, Dr Eloisa Rubio-Beltran, Migraine Trust researcher at the Wolfson Centre for Sensation, Pain and Regeneration, King’s College London, UK, said the findings should have an impact on migraine treatment guidelines.
“As the study shows, triptans should be the first-line treatment for the acute treatment of migraine due to their high efficacy and low cost. These results should inform treatment guidelines and support the inclusion of the most effective triptans in essential medicines lists to optimize treatment and ensure patients have access to more effective options,” said Rubio-Beltran.
It’s also important to note that Gepant and Zitan were developed to provide an alternative for patients who don’t see improvement with triptans, she added.
She noted that these drugs were not developed as a replacement for triptans, but rather to provide more treatment options for migraines.
“Nevertheless, this study highlights the need for further research into the pathophysiology of migraine, which may lead to the discovery of new targets and, ultimately, new treatment options that could benefit all patient populations,” she added.
This study was funded by the NIHR Oxford Health Biomedical Research Centre and the Lundbeck Foundation. Cipriani reports receiving research, teaching and consultancy fees from the Italian Paediatric Clinical Trials Network, Fondazione Cariplo, Lundbeck and Angelini Pharma. Asina is a consultant, speaker and scientific advisor for AbbVie, Amgen, AstraZeneca, Eli Lilly, GSK, Lundbeck, Novartis, Pfizer and Teva, and is a past president of the International Headache Society. Journal of Headache and Pain and brainLiggins has served as a consultant for the Gerson Lehrman Group, participated in paid research for Academic CME and the Migraine Disorders Association, served as a principal investigator for studies for Electrocor, Thelanica, and Eli Lilly, and sits on advisory boards for Thelanica, Teva, Lundbeck, Amneal Pharmaceuticals, NeurologyLive, and Miles for Migraine, and is a project advisor for the American Academy of Clinical Neurology’s Clinical Awareness Initiative. Rubio-Beltran Journal of Headache and Pain He serves as a junior representative for the International Headache Society and has received research support from The Migraine Trust, Eli Lilly and Company, CoLucid Pharmaceuticals, Inc., Amgen, Novartis, and Kallyope, and travel support from CoLucid Pharmaceuticals, Inc., Allergan, and Novartis.
