Triptans more effective than newer, more expensive migraine medications

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The most effective triptans should be promoted worldwide and guidelines updated accordingly, researchers say.

Some triptans are a more effective treatment for acute migraine than newer, more expensive drugs, according to an analysis of the latest evidence published by The BMJ Today.

Triptans work by constricting blood vessels in the brain and preventing the release of chemicals that cause pain and inflammation.

The results show that four triptans – eletriptan, rizatriptan, sumatriptan and zolmitriptan – were more effective in relieving migraine pain than the recently launched and more expensive drugs lasmiditan, rimegepant and ubrogepant, which were comparable to paracetamol and most anti-inflammatory painkillers (NSAIDs).

The researchers argue that triptans are currently largely underused. They believe that access to the most effective triptans should be promoted worldwide and international guidelines should be updated accordingly.

Migraine affects more than a billion people worldwide and is the leading cause of disability among girls and women aged 15 to 49. Numerous medications are available, but there is no clear consensus on which ones work best.

To address this issue, researchers searched scientific databases for randomized controlled trials published through June 24, 2023, comparing approved oral medications for the treatment of acute migraine in adults.

A total of 137 randomized controlled trials were included, involving 89,445 participants (mean age 40 years, 86% women) who were assigned to one of 17 single drugs or placebo. The trials were of varying quality, but researchers were able to assess the certainty of the evidence using a recognized tool.

The results show that all drugs provided better pain relief than placebo after two hours and that most, with the exception of paracetamol and naratriptan, provided sustained pain relief for up to 24 hours.

When comparing the drugs, eletriptan was found to be the most effective drug for pain relief after two hours, followed by rizatriptan, sumatriptan and zolmitriptan. For sustained pain relief up to 24 hours, eletriptan and ibuprofen were the most effective drugs.

The researchers point out that the most effective triptans are considered the treatment of choice for migraine attacks and should be included in the WHO List of Essential Medicines to promote global availability and uniform treatment standards.

They acknowledge that some people cannot take triptans due to heart problems or unpleasant side effects.

Nevertheless, they believe that these results, although limited to average treatment effects due to a lack of individual patient data, provide “the best available evidence for the selection of acute oral drug interventions for migraine attacks” and “should be used to guide the selection of treatment modalities to promote shared, informed decision-making between patients and physicians.”

Reference: Karlsson WK, Ostinelli EG, Zhuang ZA, et al. Comparative effects of drug interventions for the acute treatment of migraine episodes in adults: systematic review and network meta-analysis. BMJ. 2024:e080107. doi: 10.1136/bmj-2024-080107

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