A recent review and meta-analysis identified several effective oral medications for achieving rapid pain relief in acute migraine episodes.
In the study, published in The BMJ, investigators compared the efficacy of 17 oral drug interventions based on data from 137 randomized controlled trials involving over 89,000 participants.
The primary outcomes they measured included the percentage of participants who were pain-free 2 hours after medication and those who maintained pain relief from 2 to 24 hours without requiring additional rescue medication.
Eletriptan demonstrated the highest odds ratios (ORs) for pain relief at 2 hours, ranging from 1.46 (95% confidence interval [CI] = 1.18–1.81) to 3.01 (95% CI = 2.13–4.25), followed by rizatriptan (OR = 1.59, 95% CI = 1.18–2.17; to 2.44, 95% CI = 1.75–3.45), sumatriptan (OR = 1.35, 95% CI = 1.03–1.75; to 2.04, 95% CI = 1.49–2.86), and zolmitriptan (OR = 1.47, 95% CI = 1.04–2.08; to 1.96, 95% CI = 1.39–2.86). For sustained pain relief over 24 hours, eletriptan and ibuprofen were identified as the most efficacious interventions, with ORs ranging from 1.41 (95% CI = 1.02–1.93) to 4.82 (95% CI = 1.31–17.67).
Newer agents such as lasmiditan, rimegepant, and ubrogepant showed lower efficacy compared with triptans and had efficacy like paracetamol and many nonsteroidal anti-inflammatory drugs; however, these drugs did not have vasoconstrictive effects and were recommended as alternatives in patients who cannot use or do not tolerate triptans.
Most treatments were more effective than placebo in achieving sustained pain relief. Celecoxib showed the lowest efficacy for sustained pain freedom (OR = 1.71, 95% CI = 1.07–2.74), whereas ibuprofen demonstrated ORs between 1.41 (95% CI = 1.02–1.93) and 4.82 (95% CI = 1.31–17.67).
The study examined safety and tolerability by evaluating the proportion of participants who experienced at least one serious adverse event and those with at least one of 19 predefined clinically relevant adverse events. Common adverse events assessed included dizziness, fatigue, nausea, and sedation across different treatments. Dizziness was more frequently reported with lasmiditan, eletriptan, sumatriptan, and zolmitriptan (OR = 1.14 to 3.19), while fatigue and sedation were noted more often in participants taking eletriptan and lasmiditan (OR = 1.34 to 2.63).
All active interventions were more effective than placebo for both primary outcomes. Sensitivity analyses supported the main findings, though confidence in evidence varied from high to very low based on the Confidence in Network Meta-Analysis tool. Moderate heterogeneity was found across outcomes, with many comparisons rated as low or very low confidence, mainly because of within-study bias, imprecision, and lack of details on randomization. For pain relief at 2 hours, 8% of comparisons had moderate certainty, 17% low, and 74% very low. For sustained pain relief up to 24 hours, 4% were moderate, 5% low, and 90% very low. Eletriptan, rizatriptan, sumatriptan, and zolmitriptan showed favorable efficacy.
Full disclosures can be found in the published review.
