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Migraine league table from a systematic review

 

Clinical bottom line

A systematic review of triptans in acute migraine from Canada gives a league table for headache response and pain free outcomes at two hours.


Reference

MJ Gawel et al. A systematic review of the use of triptans in acute migraine. Canadian Journal of Neurological Science 2001 28: 30-41.

Review

This review sought to consolidate evidence for triptans available in Canada. That point is important, since the review is not comprehensive and some doses of some triptans are not reviewed. Otherwise randomised full publications of trials of triptans in migraine were sought using MEDLINE. It is not stated what the inclusion criteria were, but the trials were commercial phase 3 trials, which were double blind, and used IHS criteria for definition of migraine.

The outcomes sought were headache response at one or two hours, pain free at one or two hours, and a clinical disability score of 0 or 1 at two hours. Oral rizatriptan did not include buccal wafers, which were analysed separately from a single trial.

Results

Only the two hour results are discussed here. At one hour there was less effect ( see rizatriptan review ), but the relative positions of treatments was similar.

Headache response at two hours

For headache initially moderate or severe to disappear or be only mild at two hours, results are shown in Table 1, In Figure 1 for the NNTs and in Figure 2 for the percentage of patients benefiting. Clearly subcutaneous sumatriptan was superior, but of the oral triptans rizatriptan 10 mg was the best.

Note that treatments are comparable, with similar response rates in the placebo groups.

Table 1: Headache response at two hours

 

Percent responding to

 

Treatment

Route

Number of trials

Number of patients

Treatment

Placebo

NNT (95%CI)

Sumatriptan 6 mg

Subcut

5

818

71

21

2.0 (1.8 to 2.3)

Rizatriptan 10 mg

Oral

6

2797

74

28

2.2 (1.8 to 2.7)

Sumatriptan 50 mg

Oral

3

927

65

31

3.0 (2.5 to 3.7)

Sumatriptan 100 mg

Oral

12

2914

57

25

3.1 (2.8 to 3.4)

Sumatriptan 20 mg

Intranasal

5

1266

63

34

3.5 (3.0 to 4.3)

Zolmitriptan 2.5 mg

Oral

2

651

64

35

3.5 (2.7 to 4.7)

Naratriptan 2.5 mg

Oral

2

1437

47

28

5.1 (4.1 to 6.7)

Figure 1: NNT for headache response at 2 hours


Figure 2: Percentage of patients with headache response at 2 hours (95% confidence interval


Pain free at two hours

For headache initially moderate or severe to disappear and for patients to be pain free at two hours, results are shown in Table 2, In Figure 3 for the NNTs and in Figure 4for the percentage of patients benefiting. Clearly subcutaneous sumatriptan was superior, but of the oral triptans rizatriptan 10 mg was the best.

Note that treatments are comparable, with similar response rates in the placebo groups. For sumatriptan 6 mg subcutaneous there were only 110 patients in a single trial, so that placebo comparisons are not sensible.

Table 2: Pain free at two hours

Percent responding to

Treatment

Route

Number of trials

Number of patients

Treatment

Placebo

NNT (95%CI)

Sumatriptan 6 mg

Subcut

1

110

55

17

2.6 (1.8 to 4.8)

Rizatriptan 10 mg

Oral

6

2797

40

8

3.2 (2.9 to 3.5)

Sumatriptan 50 mg

Oral

2

834

35

9

3.9 (3.2 to 4.9)

Sumatriptan 100 mg

Oral

6

1500

28

8

4.9 (4.1 to 5.9)

Zolmitriptan 2.5 mg

Oral

2

651

25

8

5.9 (4.5 to 8.7)

Naratriptan 2.5 mg

Oral

2

1437

23

8

6.5 (5.3 to 8.5)

Figure 3: NNT for pain free at 2 hours


Figure 4: Percentage of patients with headache response at 2 hours (95% confidence interval


Clinical disability at two hours

This refers to patients who had a disability score of 0 or 1 at two hours. The results are shown in Table 3, but note the very wide differences in the rates obtained with placebo, making comparison between treatments suspect. It may actually make the outcome itself unreliable, but as no details were given of what actual outcome was used in each of the trials, it is difficult to comment.

Table 3: Clinical disability at two hours

 

Percent responding to

 

Treatment

Route

Number of trials

Number of patients

Treatment

Placebo

NNT (95%CI)

Sumatriptan 6 mg

Subcut

3

268

72

30

2.3 (1.9 to 3.1)

Rizatriptan 10 mg

Oral

5

2040

44

17

3.7 (3.2 to 4.3)

Sumatriptan 100 mg

Oral

6

1269

38

19

5.4 (4.3 to 7.4)

Sumatriptan 20 mg

Intranasal

3

1116

72

52

4.9 (3.8 to 7.0)

Sumatriptan 50 mg

Oral

4

1271

42

24

5.3 (4.1 to 7.5)

Naratriptan 2.5 mg

Oral

2

1437

66

48

5.6 (4.3 to 7.7)

Comment

This is a valuable study, despite not comprehensively covering all the doses of all the triptans. The information here agrees well with that in other systematic reviews, and for headache response at two hours summarised in a larger assessment of relative efficacy .