Acute treatments alleviate pain, functional difficulties caused by migraine

Certain acute treatments for episodic migraines improved pain and function, according to a systemic review and meta-analysis study published in JAMA.

The treatments associated with short-term improvements included triptans, NSAIDs, acetaminophen, dihydroergotamine, calcitonin gene-related peptide antagonists, lasmiditan and some nonpharmacologic treatments, such as remote electrical neuromodulation, transcranial magnetic stimulation, external trigeminal nerve stimulation and noninvasive vagus nerve stimulation. Opioids for migraine had low or insufficient evidence supporting their use.

“Choosing an acute treatment for migraine attacks requires an individualized approach for each patient; a number of factors must be considered such as patient characteristics (including age, comorbidities, and affordability/insurance coverage), migraine attack characteristics (such as severity, speed of onset, and presence of nausea/vomiting), and reported effectiveness and harms associated with available interventions,” Juliana H. VanderPluym, MD, a neurologist at the Mayo Clinic in Phoenix, and colleagues wrote. “All these factors should be considered in a shared decision-making approach.”

VanderPluym and colleagues examined the benefits and adverse events associated with several acute treatments for episodic migraines in adults. Their analysis included 15 systemic reviews, which provided evidence for triptans and NSAIDs, and 115 randomized clinical trials involving 28,803 patients with migraines, which provided evidence for the other interventions. The studies assessed were published in various databases from the point of the database’s creation to February 24, 2021, and described short-term outcomes at 4 weeks or less after the end of treatment. Patients aged 18 years and older reported experiencing episodic migraines. Primary outcomes included pain freedom and pain relief, sustained pain freedom and pain relief and adverse events.

VanderPluym and colleagues found that triptans and NSAIDs, when compared with placebo, significantly correlated with decreased pain at 2 hours and 1 day, although they were associated with an increased risk for mild and transient adverse events like nausea and dizziness. Calcitonin gene-related peptide receptor antagonists, lasmiditan, dihydroergotamine, ergotamine plus caffeine, acetaminophen, antiemetics, butorphanol and tramadol in combination with acetaminophen correlated significantly with decreased pain and an increase in mild adverse events, according to the researchers. Lasmiditan treatment produced a significantly higher risk for gastrointestinal, neurologic and serious adverse events.

Moreover, compared to placebo, several nonpharmacologic treatments significantly improved pain, including remote electrical neuromodulation, transcranial magnetic stimulation, external trigeminal nerve stimulation and noninvasive vagus nerve stimulation. Nonpharmacologic treatments and placebo demonstrated similar rates of adverse events.

“For the acute treatment of migraine, several established and newer therapies were associated with improvements in short-term pain outcomes, with varying strengths of evidence,” VanderPluym and colleagues wrote. “In contrast, the evidence for many other interventions, including opioids, was limited.”