Head-to-Head Comparison of 25 Migraine Meds Reveals Top Options

Megan Brooks

May 02, 2023

When it comes to relieving migraine headache, triptans, ergots, and antiemetics are the most effective classes of medications, a new real-world analysis of data on more than 3 million migraine attacks shows.

Dr Chia-Chun Chiang

The findings "align with results of clinical trials and recommendations from clinical treatment guidelines" and provide insights to complement clinical practice, study investigator Chia-Chun Chiang, MD, neurologist with Mayo Clinic, Rochester, Minnesota, told Medscape Medical News.

The findings were presented at the American Academy of Neurology (AAN) 2023 Annual Meeting.

The Power of Big Data

Despite a wide variety of acute migraine medications that are available, large-scale, head-to-head comparisons of treatment effectiveness from real-world patient experience reports are lacking, Chiang explained.

"To the best of our knowledge, this is the first study that simultaneously compared multiple acute migraine medications using a Big Data analysis approach based on real-world patient-provided data," she said.

The researchers extracted more than 10 million self-reported migraine attack records from a migraine smartphone app called Migraine Buddy, where users can document whether a treatment was helpful, somewhat helpful, unsure or unhelpful.

They analyzed 25 acute medications among seven classes: acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), triptans, combination analgesics (acetaminophen/aspirin/caffeine), ergots, antiemetics, and opioids. The newer gepants and ditan medication classes of medications were not included because of the relatively lower numbers of usage when data was extracted (2014-2020).

They employed a two-level nested logistic regression model to analyze the odds of treatment effectiveness of each medication by adjusting concurrent medications and the covariance within the same user.

The final analysis included more than 3.1 million migraine attacks among 278,000 users globally.

Using ibuprofen as the reference, triptans, ergots, and antiemetics had the highest efficacy with mean odds ratios (ORs) of 4.8, 3.02 and 2.67, respectively, followed by opioids (OR, 2.49), NSAIDs (OR, 1.94), combination analgesics (OR, 1.69), others (OR, 1.49), and acetaminophen, (OR, 0.83).

Individual medications with the highest patient-reported effectiveness were eletriptan (Relpax; OR 6.1), zolmitriptan (Zomig; OR 5.7) and sumatriptan (Imitrex; OR 5.2).

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," Chiang said.

End of Trial-and-Error?

Commenting on this research for Medscape Medical News, Shaheen Lakhan, MD, PhD, a neurologist and researcher in Boston, said "This is a great study of Big Data in that it shows the power of the smartphone to collect real-world data and smart researchers like at Mayo Clinic to analyze them."

"The study sheds light on how different therapeutics compare to each other. The next iteration of this line of research, I would hope, would be to determine if particular medications are effective for a particular migraine population, and even down to individuals with migraine," said Lakhan, who wasn’t involved in the study.

"Once those models are appropriately built, long gone will be the era of trial-and-error medicine and truly personalized healthcare," Lakhan added.

The study had no specific funding. Chiang has served as a c onsultant for Satsuma. Lakhan reports no relevant financial relationships.

American Academy of Neurology (AAN) 2023 Annual Meeting. Abstract 2258. Presented April 26, 2023.

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