Acute Treatments for Episodic Migraine in Adults

Abstract

IMPORTANCEMigraine is common and can be associated with significant morbidity, and several treatment options exist for acute therapy.OBJECTIVE To evaluate the benefits and harms associated with acute treatments for episodic migraine in adults.DATA SOURCES Multiple databases from database inception to February 24, 2021.STUDY SELECTION Randomized clinical trials and systematic reviews that assessed effectiveness or harms of acute therapy for migraine attacks.DATA EXTRACTION AND SYNTHESIS Independent reviewers selected studies and extracted data. Meta-analysis was performed with the DerSimonian-Laird random-effects model with Hartung-Knapp-Sidik-Jonkman variance correction or by using a fixed-effect model based on the Mantel-Haenszel method if the number of studies was small. MAIN OUTCOMES AND MEASURESThe main outcomes included pain freedom, pain relief, sustained pain freedom, sustained pain relief, and adverse events. The strength of evidence (SOE) was graded with the Agency for Healthcare Research and Quality Methods Guide for Effectiveness and Comparative Effectiveness Reviews.FINDINGS Evidence on triptans and nonsteroidal anti-inflammatory drugs was summarized from 15 systematic reviews. For other interventions, 115 randomized clinical trials with 28 803 patients were included. Compared with placebo, triptans and nonsteroidal anti-inflammatory drugs used individually were significantly associated with reduced pain at 2 hours and 1 day (moderate to high SOE) and increased risk of mild and transient adverse events. Compared with placebo, calcitonin gene-related peptide receptor antagonists (low to high SOE), lasmiditan (5-HT 1F receptor agonist; high SOE), dihydroergotamine (moderate to high SOE), ergotamine plus caffeine (moderate SOE), acetaminophen (moderate SOE), antiemetics (low SOE), butorphanol (low SOE), and tramadol in combination with acetaminophen (low SOE) were significantly associated with pain reduction and increase in mild adverse events. The findings for opioids were based on low or insufficient SOE. Several nonpharmacologic treatments were significantly associated with improved pain, including remote electrical neuromodulation (moderate SOE), transcranial magnetic stimulation (low SOE), external trigeminal nerve stimulation (low SOE), and noninvasive vagus nerve stimulation (moderate SOE). No significant difference in adverse events was found between nonpharmacologic treatments and sham.CONCLUSIONS AND RELEVANCE There are several acute treatments for migraine, with varying strength of supporting evidence. Use of triptans, nonsteroidal anti-inflammatory drugs, acetaminophen, dihydroergotamine, calcitonin gene-related peptide antagonists, lasmiditan, and some nonpharmacologic treatments was associated with improved pain and function. The evidence for many other interventions, including opioids, was limited.

Paracetamol: A Review of Guideline Recommendations

“…Recently, Abdel Shaheed analyzed data from 36 publications and reported that paracetamol produced modest pain relief in hip and knee osteoarthritis, tension headache, and post-craniotomy pain and that it was ineffective in other conditions [ 145 ]; the authors concluded with the need for large, high-quality trials to reduce uncertainty about the efficacy of paracetamol in common pain conditions. In the last few months, new published studies report the safe use of paracetamol in patients with chronic kidney disease [ 147 ], the significant efficacy of paracetamol for post-arthroplasty pain [ 148 ], the lesser efficacy of paracetamol than ibuprofen for post-laminectomy pain [ 149 ], the opioid-sparing effects of paracetamol in the Emergency Department [ 150 ], the recommendations against paracetamol in lumbar spinal stenosis with neurogenic claudication [ 151 ], and the recommendations in favor of paracetamol for postcesarean pain [ 152 ] and for migraine [ 153 , 154 ].…”

Migraine and Current Pharmacologic Management

“…Triptans, nonsteroidal anti-inflammatory drugs (NSAIDs), topiramate, and the newer monoclonal antibodies (mAbs) were prescribed to these patients based on local availability and best practices, frequency of attacks, the physicians' therapeutic knowledge of the risk profile of the selected medicine, and other comorbidities such as BMI and smoking status. Several factors determine the precise pharmacological choice in each situation [1,2,[4][5][6][9][10][11][12][13][14][15][16][17][20][21][22][23][24], including the nature and severity of the migraine, the presence and severity of comorbidities, the most expedient route of administration at presentation (transdermal, intranasal, intravenous, intramuscular, or oral), safety and side effect profile, and, most importantly, the patient's treatment response. Furthermore, some writers and recommendations have advocated a stratified and personalized therapy strategy [1,2,[4][5][6][9][10][11][12][13][14][15][16][17][20][21][22][23][24].…”

“…Several factors determine the precise pharmacological choice in each situation [1,2,[4][5][6][9][10][11][12][13][14][15][16][17][20][21][22][23][24], including the nature and severity of the migraine, the presence and severity of comorbidities, the most expedient route of administration at presentation (transdermal, intranasal, intravenous, intramuscular, or oral), safety and side effect profile, and, most importantly, the patient's treatment response. Furthermore, some writers and recommendations have advocated a stratified and personalized therapy strategy [1,2,[4][5][6][9][10][11][12][13][14][15][16][17][20][21][22][23][24].…”

“…When compared to earlier decades, the combination of newer innovations and safer drugs has improved migraine treatment outcomes [2,[9][10][11][12][13][14][15][16]. However, as the search for more novel breakthroughs in migraine therapy continues, there is a need for a more individualized strategy to enhance treatment results by carefully evaluating modifiable risk factors that may inhibit good outcomes, such as excessive use of acute migraine drugs, ineffective therapy, obesity, smoking, excessive caffeine consumption, high-fat diets, anxiety, frequency of attacks, acute medication overuse, caffeine overuse, sleep disorders, and depression [1][2][3][4][5][6][9][10][11][12][13][14][15][16][17][18][19][20]. If undertreated or untreated, a migraine may lead to common complications that include migraine progression to chronic migraine, seizures, and strokes.…”

Progress in the Treatment of Migraine Attacks: From Traditional Approaches to Eptinezumab

“…The therapeutic options described above demonstrate, with a large degree of strength, the evidence of the efficacy (limited only for opioids [ 40 ]) and the great translational success of the research effort of the last 30 years; however, a safe abortive treatment for acute attacks effective in most patients is still lacking. Recently, potassium channels have gained interest in the field of migraine.…”