This report reflects the changing nature of guidelines toward evidence-based treatment rather than expert opinion. A companion piece will help translate evidence-based guidelines to clinical practice.
An updated assessment of the most effective medications for acute migraine will form the basis of new treatment guidelines provided by the American Headache Society (AHS), according to a new systematic review.
Drug classes found in the study to meet criteria as “effective” for treating patients with acute migraine include triptans, dihydroergotamine, many NSAIDs, butorphanol nasal spray, and the combination medications sumatriptan/naproxen and acetaminophen/aspirin/caffeine.
Several other medications were considered “probably effective,” including ergotamine and other forms of dihydroergotamine, ketoprofen, intravenous and intramuscular ketorolac, flurbiprofen, intravenous magnesium (in migraine with aura), and the combination of isometheptene compounds, codeine/acetaminophen and tramadol/acetaminophen, as well as the antiemetics prochlorperazine, droperidol, chlorpromazine, and metoclopramide.
Although opioids such as butorphanol, codeine/acetaminophen, and tramadol/acetaminophen are probably effective, they are not recommended for regular use.
“This report focusing on acute migraine treatment reflects the changing nature of guidelines toward evidence-based treatment rather than expert opinion,” said lead author Michael J. Marmura, MD, of the Department of Neurology, Jefferson Headache Center, Thomas Jefferson University, in Philadelphia. “Large double-blind, placebo-controlled trials are the basis of determining the effectiveness of acute migraine treatment. Some clinical trials for headache performed prior to publication of the previous guidelines do not meet the more rigorous standards for clinical trials today.”
The researchers conducted a systematic review of clinical trials on the efficacy of acute migraine treatments versus placebo, published in medical journals between 1998 and 2013. The authors’ original research identified 805 articles, of which 132 were selected for review. Previous guidelines on acute migraine treatment were published in 2000 by the American Academy of Neurology and the AHS.
Based on ratings, each class of drugs was deemed effective (Level A), probably effective (Level B), or possibly effective (Level C) or judged to have inadequate or conflicting evidence to support or refute the medications’ use (Level U). The determination of each efficacy level also was based on the rigor and quantity of published studies on the drug class. To be in Level A, for example, a class of drugs must have been supported by at least 2 “Class I” studies, that is, well-designed, double-blind, randomized, placebo-controlled clinical trials.
The researchers noted that clinicians must consider medication efficacy, potential adverse effects, and possible medication-related adverse events when prescribing acute medications for migraine.
“This review focuses on the treatment of acute migraine attacks, rather than long-term outcomes,” Dr Marmura said. “Clinicians still need to individualize treatment and consider the clinical context of the migraine attack. An outpatient with well-controlled episodic migraine may respond differently than someone with chronic migraine or a patient in the emergency room.”
He added that the assessment does not provide guidance for long-term migraine management, including issues such as adverse events and medication-overuse headache.
Based on this assessment, the AHS Guidelines Committee is developing and will publish a companion piece that will help translate these evidence-based guidelines to clinical practice.
The researchers published their results in the January issue of journal Headache.