A new meta-analysis published in The BMJ indicates that older, less expensive triptan medications are more effective in treating acute migraine attacks compared to newer, costlier drugs like gepants. The study, which analyzed 137 randomized controlled trials involving nearly 90,000 participants, suggests a need to revisit current treatment guidelines.
Triptans vs. Gepants: A Comparative Look
The research team, led by Andrea Cipriani from the University of Oxford, compared 17 different oral treatments for migraine. The analysis focused on the proportion of participants who were pain-free two hours post-dose and those with sustained pain freedom from two to 24 hours without rescue medication.
Key findings revealed that eletriptan was the most effective drug for achieving pain freedom at two hours, followed by rizatriptan, sumatriptan, and zolmitriptan. These triptans also demonstrated superior performance compared to newer drugs like lasmiditan, rimegepant (Vydura), and ubrogepant (Ubrelvy). The gepants, marketed by companies such as Pfizer and AbbVie, were found to be only as effective as paracetamol and anti-inflammatory painkillers.
Clinical Implications and Expert Opinions
"Our analysis identified eletriptan, rizatriptan, sumatriptan, and zolmitriptan as the most effective medications for treating acute migraine attacks," said Cipriani. He noted that current guidelines treat all oral triptans as equally viable, but the research indicates a preference order that necessitates updates to clinical practice guidelines.
Despite their effectiveness, triptans are underused, with only a small percentage of migraine sufferers utilizing them. The researchers emphasize the need to better inform healthcare professionals and policymakers about the benefits of triptans to ensure optimal patient care.
Nina Riggins, a headache neurologist from the Headache Center of Excellence of Palo Alto VA Medical Center, highlighted the potential for this study to facilitate discussions with primary care clinicians about specific migraine treatments. She also noted that triptans could be more accessible than gepants due to cost, especially in underserved areas.
Considerations and Limitations
While triptans are effective, they are not without risks. They are contraindicated in patients with cardiovascular conditions due to their vasoconstrictive properties. Eletriptan, for example, was associated with chest pain in some patients. Medhat Mikhael, a pain management specialist, cautioned that triptans' vasoconstrictive effects extend to coronary arteries, making them unsuitable for patients with cardiac conditions.
The study also acknowledges limitations, including the exclusion of certain data and the potential for bias due to pharmaceutical industry sponsorship of many trials. The certainty of evidence varied from high to very low across comparisons, and further research is needed to reexamine the vascular contraindications for triptans.
The Broader Context of Migraine Treatment
Migraines affect approximately 10% of people worldwide and are a leading cause of disability, particularly among young women. The economic burden of migraines is substantial, encompassing healthcare costs and lost productivity. This meta-analysis underscores the importance of effective and accessible treatments for managing this debilitating condition.
