Which are most effective medications for migraine?

Using a big-data approach, the researchers analyzed patient-generated real-time records of 10 million migraine attacks, and simultaneous head-to-head comparisons of 25 acute migraine medications were conducted. They found that anti-emetics, ergots, and triptans are the most effective classes of medications, their findings aligned with the guideline recommendations and offered generalizable insights to complement clinical practice.

"For relief of acute migraine, ergots, triptans, and antiemetics are two to five times more effective than ibuprofen, and acetaminophen is the least effective medication," the researchers reported.

There are several acute treatment options for migraine. However, there is a lack of large-scale, head-to-head comparisons of treatment effectiveness from real-world patient experience reports. Therefore, Chia-Chun Chiang, Department of Neurology, Mayo Clinic, Rochester, MN, United States, and colleagues simultaneously compared 25 acute migraine medications based on self-reported records of 10 million users from a smartphone application.

A retrospective analysis was done of 10,842,795 migraine attack records extracted from an e-diary smartphone application between 2014 and 2020. 25 acute medications were analyzed among seven classes -- NSAIDs, opioids, anti-emetics, ergots, combination analgesics, acetaminophen., and triptans. The analysis did not include ditan and gepants.

Different formulations and doses of each medication were combined according to the generic names. A two-level nested logistic regression model was employed to analyze the odds ratio (OR) of treatment effectiveness of each medication by adjusting concurrent medications and the covariance within the same user. Subgroup analyses were conducted for users in the United Kingdom (UK), the United States (US), and Canada (CAN).

The final analysis included 4,777,524 medication-outcome pairs from 3,119,517 migraine attacks among 278,006 users.

The researchers reported the following findings:

• Triptans (mean OR 4.8), anti-emetics (mean OR 2.67), and ergots (mean OR 3.02), were the top three classes of medications with the highest effectiveness, followed by opioids (mean OR 2.49), NSAIDs (other than ibuprofen, mean OR 1.94), combination analgesics (acetaminophen/acetylsalicylic acid/caffeine) (OR 1.69), others (OR 1.49), and acetaminophen (OR 0.83), using ibuprofen as the reference.
• Individual medications with the highest ORs were eletriptan (OR 6.1), zolmitriptan (OR 5.7), and sumatriptan (OR 5.2).
• The ORs of acetaminophen, NSAIDs, combination analgesics and opioids were mostly around or less than 1, suggesting similar or lower reported effectiveness compared to ibuprofen.
• The ORs for 24 medications, except that of acetylsalicylic acid, achieved statistical significance, and the nested logistic regression model achieved an area under the curve (AUC) of 0.849.
• Country-specific subgroup analyses revealed similar ORs of each medication and AUC (US 0.849, UK 0.864, and CAN 0.842), demonstrating the robustness of the analysis.

"The findings provide Class IV evidence that for migraine patients, selected acute medications (e.g., triptans, ergots, anti-emetics) are associated with higher odds of user-rated positive response than ibuprofen," the researchers concluded.

Reference:

The study titled, "Simultaneous Comparisons of 25 Acute Migraine Medications Based on 10 Million Users’ Self-Reported Records From a Smartphone Application," was published in the journal Neurology. DOI: https://doi.org/10.1212/WNL.0000000000207964