Triptans ‘most effective’ for migraine and should be first choice, say researchers

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By Emma Wilkinson

Triptans are the most effective treatment for migraine according to a large, detailed analysis that showed they outperform newer more expensive drugs.

The findings suggest that triptans are widely underused and guidelines should be updated to reflect their superiority compared with other treatments, the researchers concluded in the BMJ.

A comparison using data from 137 randomised controlled trials of almost 90,000 patients found that eletriptan, rizatriptan, sumatriptan, and zolmitriptan were the best options of all treatments when both efficacy and tolerability were taken into account.

They were also more effective than the more recently marketed and more expensive drugs lasmiditan, rimegepant, and ubrogepant, which were found to be on a par with paracetamol and most non-steroidal anti-inflammatory drugs.

All treatments had been shown in studies to be better than placebo at relieving pain but that does not help clinicians decide between the different options, the researchers from across Europe including the University of Oxford said.

Triptans are selective serotonin receptor agonists which both narrow blood vessels in the brain and prevent the release of chemicals that cause pain and inflammation.

They are cheap but underused, the researchers said, with rates in Europe varying from 3.4% to 22.5% among people with migraine. They are contraindicated in patients with vascular disease but more research is needed to fully unpick these risks, they added.

Some patients cannot take them because they cannot tolerate the side effects.

'Treatment of choice'

When all the drugs were compared with each other, eletriptan was the most effective drug for pain relief at 2 hours, the researchers said, followed by rizatriptan, sumatriptan, and zolmitriptan.

For sustained pain relief up to 24 hours, the most effective drugs were eletriptan and ibuprofen.

Migraine affects more than one billion people worldwide and is the leading cause of disability in girls and women aged 15 to 49 years.

The clear results suggest the best performing triptans should be considered the treatment of choice for migraine episodes and should be included into the WHO Model List of Essential Medicines, they concluded.

Study author Professor Andrea Cipriani, professor of psychiatry and director of the Oxford Health Clinical Research Facility said many drugs were licensed for migraine with different mechanisms of action but there had been no clinical consensus on which should be prescribed initially.

He explained that the analysis had taken 3 years because much of the data they had included had been unpublished.

“If you look at the total spending across all GP practices in England for anti-migraine drugs you can see that in the past two years there has been an increase in costs. Compared to 2022 it has almost doubled so there is an important economic impact.

“We need to revise the existing guidelines because at the moment they treat all oral treatments as equally viable options.”

Co-author Professor Messoud Ashina, professor of neurology at the University of Copenhagen in Denmark said when they were first introduced in the 1990s price was probably a barrier to the use of triptans.

“But we still see underutilisation probably because there is also a perception that these are very strong medications and people still see them as something special.”

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