Pharmacologic Treatment of Acute Attacks of Episodic Migraine: A Systematic Review and Network Meta-analysis for the American College of Physicians

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Abstract
Migraine is common, affecting 15% of Americans. To compare benefits and harms of pharmacologic treatments for acute attacks of episodic migraine in adults and assess cost-effectiveness. Three electronic databases searched to October 2024, gray literature, and reference lists. Two investigators independently selected English-language randomized trials. Single reviewer data extraction with second review. Dual independent risk of bias and certainty of evidence (COE) assessment. Twenty-one head-to-head and 165 placebo-controlled trials were included in meta-analyses and network meta-analyses. Triptans were more effective than acetaminophen (low COE) and nonsteroidal anti-inflammatory drugs (NSAIDs) (high COE) for pain outcomes at 2 hours and pain freedom up to 48 hours. Triptan and acetaminophen combinations were more effective than acetaminophen alone (moderate COE) for pain outcomes at 2 hours and pain freedom up to 48 hours but not more than triptans alone (low COE). Triptan and NSAID combinations were more effective for pain outcomes at 2 hours and pain freedom up to 48 hours compared with acetaminophen (low COE), gepants (low COE), NSAIDs (high COE), and triptan monotherapy (moderate COE). Triptan regimens, however, often had a higher risk for adverse events. One study found triptans more cost-effective than ditans and gepants. Harms assessment was limited to randomized trials. Many comparisons lacked sufficient evidence to draw conclusions. Triptans and combinations of triptans were more effective than NSAID and acetaminophen alone. American College of Physicians. (PROSPERO: CRD42023441146).

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