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Study Rates Migraine Medications

Experts review the good, the bad, and the doubtful

The cornerstone of the medical treatment of migraine is acute pharmacotherapy, and many acute migraine treatments have evidence supporting efficacy. In prescribing these drugs to migraine patients, clinicians must consider efficacy data in light of the potential for treatment-emergent adverse events, as well as patient-specific contraindications and drug interactions.

Since 2000, when the last American Academy of Neurology (AAN) guidelines for the acute treatment of migraine were published, many large, randomized acute pharmacological migraine treatment trials have been conducted. Just as important, the evidence criteria for judging efficacy have changed; 2-hour headache freedom has replaced 2-hour headache relief as the key outcome measure. According to the American Headache Society (AHS), the need for updated guidelines was complicating the evidence-based practice of headache medicine.

In the January issue of Headache, experts at Thomas Jefferson University in Philadelphia, Pennsylvania, and at the Mayo Clinic in Scottsdale, Arizona, on behalf of the AHS and in cooperation with the AAN, have published an updated assessment of current evidence to answer the question, “Which pharmacological therapies are effective in treating acute migraine?”

The authors conducted a standardized literature search to identify articles related to acute migraine treatment published between 1998 and 2013.

The investigators concluded that triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan [oral, nasal spray, injectable, and transcutaneous patch], zolmitriptan [oral and nasal spray]), and dihydroergotamine (nasal spray and inhaler) are “effective” in treating acute migraine. Ergotamine and other forms of dihydroergotamine are “probably effective.”

Other “effective” medications include acetaminophen, nonsteroidal anti-inflammatory drugs (aspirin, diclofenac, ibuprofen, and naproxen), opioids (butorphanol nasal spray), sumatriptan/naproxen, and the combination of acetaminophen/aspirin/caffeine. Ketoprofen, intravenous (IV) and intramuscular ketorolac, flurbiprofen, IV magnesium (in migraine with aura), and the combination of isometheptene compounds, codeine/acetaminophen, and tramadol/acetaminophen are “probably effective.” The antiemetics prochlorperazine, droperidol, chlorpromazine, and metoclopramide are also “probably effective.”

The authors point out that there is inadequate evidence for butalbital and butalbital combinations, phenazone, IV tramadol, methadone, butorphanol or meperidine injections, intranasal lidocaine, and corticosteroids, including dexamethasone. Octreotide is “probably not effective.”

Further, there is inadequate evidence to refute the efficacy of ketorolac nasal spray, IV acetaminophen, chlorpromazine injection, and IV granisetron.

Although opioids, such as butorphanol, codeine/acetaminophen, and tramadol/acetaminophen, are “probably effective,” they are not recommended for regular use, the authors say.

They recommend that clinicians consider medication efficacy and potential medication-related adverse events when prescribing acute medications for migraine.

The AHS Guidelines Committee is planning to publish a companion piece that will facilitate application of these evidence-based guidelines in daily practice.

Migraine headaches affect approximately 36 million Americans, according to the American Migraine Foundation.

Sources: AHS; January 20, 2015; Headache; January 20, 2015.


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