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Migraine league table:

acute treatments and two hour headache response

There are a number of treatments available for acute migraine. This page summarises their efficacy in several ways. The information is drawn predominantly from systematic reviews of comparable trials. The important points that make the treatments comparable are as follows:

So what we have here is a consistent data set. We can tell it is consistent by examining the placebo responses for the treatments - they are all about 30%. This does not mean that placebo caused migraine pain to disappear, rather the pain would have faded to mild or no pain in about 30% of patients without treatment - the natural history of migraine pain if you like.


Dangers of over-interpretation

Information from league tables is sometimes over-interpreted. It should not be used to exclude treatments from formularies, for instance. rather we should celebrate the fact that we have so many effective remedies. Some arguments against over-interpretation follow:

Patient choice, and professional choice, will be influenced by many factors. Analgesic efficacy is only one. Moreover, relative efficacy should be used as a tool to guide personal and professional choice, and not be used as a rule to exclude certain types of treatment because of cost or convenience.

So please use the league table as you would a walking stick. Use it to help you and not to beat others.


Information provided

The information here has been collected from reviews (and for paracetamol 1000 mg from a single large RCT). The table gives all the information we thought relevant, including the number of trials and patients from which the table is drawn. The two figures show the results graphically for NNTs, and for the proportion of patients with headache response at two hours. In the figures subcutaneous treatments are in red , and intranasal treatments in green ; all other treatments are oral, with oral treatments that are not triptans in yellow..


Table of relative efficacy of acute migraine treatments - headache response at two hours

Active treatment

Placebo treatment

Treatment

Route

Number of trials

Number/

Total

%

Number/

Total

%

NNT

(95% CI)

Sumatriptan 6 mg

Subcut

8

379/477

79

131/461

28

2.0 (1.8 to 2.2)

Eletriptan 80 mg

Oral

6

763/1221

62

191/779

25

2.6 (2.4 to 3.0)

Rizatriptan 10 mg

Oral

7

1219/1783

68

303/987

31

2.7 (2.4 to 2.9)

Eletriptan 40 mg

Oral

6

724/1224

59

191/779

25

2.9 (2.6 to 3.3)

Zolmitriptan 5 mg

Oral

4

583/943

62

85/285

30

3.1 (2.6 to 3.9)

Aspirin 900 mg + metoclopramide 10 mg

Oral

N/A

214/376

57

95/373

25

3.2 (2.6 to 4.0)

Sumatriptan 100 mg

Oral

13

1346/2311

58

336/1211

28

3.3 (3.0 to 3.7)

Sumatriptan 20 mg

Intranasal

6

571/907

63

185/546

34

3.4 (2.9 to 4.1)

Zolmitriptan 2.5 mg

Oral

2

279/438

64

74/213

35

3.5 (2.7 to 4.7)

Rizatriptan 5 mg

Oral

4

548/933

59

234/713

33

3.9 (3.3 to 4.7)

Sumatriptan 50 mg

Oral

6

532/1042

51

137/510

27

4.1 (3.4 to 5.2)

Eletriptan 20 mg

Oral

2

157/349

45

78/353

22

4.4 (3.4 to 6.2)

Paracetamol 1000 mg

Oral

1

85/147

58

55/142

39

5.2 (3.3 to 13)

Naratriptan 2.5 mg

Oral

2

154/340

45

61/229

27

5.4 (3.8 to 9.2)


Figure 1: Numbers needed to treat for two hour headache response compared with placebo (bars are 95% confidence interval of the NNT)


Figure 2: Percentage of patients with two hour headache response for each treatment (bars are 95% confidence interval of the percentage)