Which medication is most effective for treating acute migraine?

Numerous options exist for the treatment of acute migraine. However, large-scale, head-to-head comparisons of treatment effectiveness from real-world patient experience reports are lacking.¹

To examine this issue, researchers undertook a cross-sectional analysis of 10,842,795 migraine attack records from an e-diary smartphone application between June 30, 2014, and July 2, 2020.¹ 

The authors examined 25 acute migraine medications among seven classes—acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), triptans, combination analgesics, ergots, antiemetics and opioids. The study did not include gepants (e.g., ubrogepant) or ditans (e.g., lasmiditan–not marketed in Canada), because these drugs were not yet in wide use at the time of the study.¹

The researchers determined the odds ratio (OR) of treatment effectiveness of each medication. Subgroup analyses were conducted for users in the United States, United Kingdom and Canada.¹

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Results showed the following:

• The final analysis included 3,119,517 migraine attacks among 278,006 patients. 
• Using ibuprofen as the reference, triptans (mean OR 4.8), ergots (mean OR 3.02), and antiemetics (mean OR 2.67) were the top three classes of medications with the highest effectiveness, followed by opioids (mean OR 2.49), NSAIDs (mean OR 1.94), acetaminophen/acetylsalicylic acid/caffeine (OR 1.69), others (OR 1.49) and acetaminophen (OR 0.83). 
• Individual medications with the highest ORs were eletriptan (OR 6.1), zolmitriptan (OR 5.7) and sumatriptan(OR 5.2). The ORs for 24 medications, except that of acetylsalicylic acid, achieved statistical significance. 
• Country-specific subgroup analyses (US, UK and Canada) revealed similar ORs for each medication.¹

These results were presented in abstract form at the 2023 Annual Meeting of the American Academy of Neurology; the full study results have yet to be published. 

The authors conclude that their analysis of patient-generated real-time records of millions of migraine attacks revealed that triptans, ergots and antiemetics are the most effective classes of medications for treating acute migraine.¹ 

Lead author Chia-Chun Chiang, MD, Assistant Professor of Neurology at the Mayo Clinic in Rochester, Minnesota commented that this migraine medication comparative effectiveness analysis, based on patient-reported outcomes, "supports and complements the treatment recommendations from national headache societies based on randomized controlled trials and meta-analyses, and strongly support the use of triptans."²

References

1. Chiang CC, Fang X, Horvath Z, et al. Simultaneous comparisons of 25 acute migraine medications: a big data analysis of 10 million patient self-reported treatment records from a migraine smartphone application (abstract).  American Academy of Neurology Annual Meeting 2023. (accessed May 4, 2023).

2. Brooks M. Head-to-head comparison of 25 migraine meds reveals top options. Medscape Pharmacists, May 02, 2023. (accessed May 4, 2023).