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Acute Treatments for Episodic Migraine in Adults: A Systematic Review and Meta-analysis.
JAMA. 2021 06 15; 325(23):2357-2369.JAMA

Abstract

Importance

Migraine is common and can be associated with significant morbidity, and several treatment options exist for acute therapy.

Objective

To evaluate the benefits and harms associated with acute treatments for episodic migraine in adults.

Data Sources

Multiple databases from database inception to February 24, 2021.

Study Selection

Randomized clinical trials and systematic reviews that assessed effectiveness or harms of acute therapy for migraine attacks.

Data Extraction and Synthesis

Independent reviewers selected studies and extracted data. Meta-analysis was performed with the DerSimonian-Laird random-effects model with Hartung-Knapp-Sidik-Jonkman variance correction or by using a fixed-effect model based on the Mantel-Haenszel method if the number of studies was small.

Main Outcomes and Measures

The main outcomes included pain freedom, pain relief, sustained pain freedom, sustained pain relief, and adverse events. The strength of evidence (SOE) was graded with the Agency for Healthcare Research and Quality Methods Guide for Effectiveness and Comparative Effectiveness Reviews.

Findings

Evidence on triptans and nonsteroidal anti-inflammatory drugs was summarized from 15 systematic reviews. For other interventions, 115 randomized clinical trials with 28 803 patients were included. Compared with placebo, triptans and nonsteroidal anti-inflammatory drugs used individually were significantly associated with reduced pain at 2 hours and 1 day (moderate to high SOE) and increased risk of mild and transient adverse events. Compared with placebo, calcitonin gene-related peptide receptor antagonists (low to high SOE), lasmiditan (5-HT1F receptor agonist; high SOE), dihydroergotamine (moderate to high SOE), ergotamine plus caffeine (moderate SOE), acetaminophen (moderate SOE), antiemetics (low SOE), butorphanol (low SOE), and tramadol in combination with acetaminophen (low SOE) were significantly associated with pain reduction and increase in mild adverse events. The findings for opioids were based on low or insufficient SOE. Several nonpharmacologic treatments were significantly associated with improved pain, including remote electrical neuromodulation (moderate SOE), transcranial magnetic stimulation (low SOE), external trigeminal nerve stimulation (low SOE), and noninvasive vagus nerve stimulation (moderate SOE). No significant difference in adverse events was found between nonpharmacologic treatments and sham.

Conclusions and Relevance

There are several acute treatments for migraine, with varying strength of supporting evidence. Use of triptans, nonsteroidal anti-inflammatory drugs, acetaminophen, dihydroergotamine, calcitonin gene-related peptide antagonists, lasmiditan, and some nonpharmacologic treatments was associated with improved pain and function. The evidence for many other interventions, including opioids, was limited.

Authors+Show Affiliations

Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota. Department of Neurology, Mayo Clinic, Scottsdale, Arizona.Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota. Department of Neurology, Mayo Clinic, Scottsdale, Arizona.Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota. Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota. Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota. Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota. Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota. Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota. Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota. Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota. Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota. Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota. Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.Department of Library-Public Services, Mayo Clinic, Rochester, Minnesota.Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota. Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota. Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota. Division of Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota.

Pub Type(s)

Journal Article
Meta-Analysis
Research Support, U.S. Gov't, P.H.S.
Systematic Review

Language

eng

PubMed ID

34128998

Citation

VanderPluym, Juliana H., et al. "Acute Treatments for Episodic Migraine in Adults: a Systematic Review and Meta-analysis." JAMA, vol. 325, no. 23, 2021, pp. 2357-2369.
VanderPluym JH, Halker Singh RB, Urtecho M, et al. Acute Treatments for Episodic Migraine in Adults: A Systematic Review and Meta-analysis. JAMA. 2021;325(23):2357-2369.
VanderPluym, J. H., Halker Singh, R. B., Urtecho, M., Morrow, A. S., Nayfeh, T., Torres Roldan, V. D., Farah, M. H., Hasan, B., Saadi, S., Shah, S., Abd-Rabu, R., Daraz, L., Prokop, L. J., Murad, M. H., & Wang, Z. (2021). Acute Treatments for Episodic Migraine in Adults: A Systematic Review and Meta-analysis. JAMA, 325(23), 2357-2369. https://doi.org/10.1001/jama.2021.7939
VanderPluym JH, et al. Acute Treatments for Episodic Migraine in Adults: a Systematic Review and Meta-analysis. JAMA. 2021 06 15;325(23):2357-2369. PubMed PMID: 34128998.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Acute Treatments for Episodic Migraine in Adults: A Systematic Review and Meta-analysis. AU - VanderPluym,Juliana H, AU - Halker Singh,Rashmi B, AU - Urtecho,Meritxell, AU - Morrow,Allison S, AU - Nayfeh,Tarek, AU - Torres Roldan,Victor D, AU - Farah,Magdoleen H, AU - Hasan,Bashar, AU - Saadi,Samer, AU - Shah,Sahrish, AU - Abd-Rabu,Rami, AU - Daraz,Lubna, AU - Prokop,Larry J, AU - Murad,Mohammad Hassan, AU - Wang,Zhen, PY - 2021/6/15/entrez PY - 2021/6/16/pubmed PY - 2021/7/6/medline SP - 2357 EP - 2369 JF - JAMA JO - JAMA VL - 325 IS - 23 N2 - Importance: Migraine is common and can be associated with significant morbidity, and several treatment options exist for acute therapy. Objective: To evaluate the benefits and harms associated with acute treatments for episodic migraine in adults. Data Sources: Multiple databases from database inception to February 24, 2021. Study Selection: Randomized clinical trials and systematic reviews that assessed effectiveness or harms of acute therapy for migraine attacks. Data Extraction and Synthesis: Independent reviewers selected studies and extracted data. Meta-analysis was performed with the DerSimonian-Laird random-effects model with Hartung-Knapp-Sidik-Jonkman variance correction or by using a fixed-effect model based on the Mantel-Haenszel method if the number of studies was small. Main Outcomes and Measures: The main outcomes included pain freedom, pain relief, sustained pain freedom, sustained pain relief, and adverse events. The strength of evidence (SOE) was graded with the Agency for Healthcare Research and Quality Methods Guide for Effectiveness and Comparative Effectiveness Reviews. Findings: Evidence on triptans and nonsteroidal anti-inflammatory drugs was summarized from 15 systematic reviews. For other interventions, 115 randomized clinical trials with 28 803 patients were included. Compared with placebo, triptans and nonsteroidal anti-inflammatory drugs used individually were significantly associated with reduced pain at 2 hours and 1 day (moderate to high SOE) and increased risk of mild and transient adverse events. Compared with placebo, calcitonin gene-related peptide receptor antagonists (low to high SOE), lasmiditan (5-HT1F receptor agonist; high SOE), dihydroergotamine (moderate to high SOE), ergotamine plus caffeine (moderate SOE), acetaminophen (moderate SOE), antiemetics (low SOE), butorphanol (low SOE), and tramadol in combination with acetaminophen (low SOE) were significantly associated with pain reduction and increase in mild adverse events. The findings for opioids were based on low or insufficient SOE. Several nonpharmacologic treatments were significantly associated with improved pain, including remote electrical neuromodulation (moderate SOE), transcranial magnetic stimulation (low SOE), external trigeminal nerve stimulation (low SOE), and noninvasive vagus nerve stimulation (moderate SOE). No significant difference in adverse events was found between nonpharmacologic treatments and sham. Conclusions and Relevance: There are several acute treatments for migraine, with varying strength of supporting evidence. Use of triptans, nonsteroidal anti-inflammatory drugs, acetaminophen, dihydroergotamine, calcitonin gene-related peptide antagonists, lasmiditan, and some nonpharmacologic treatments was associated with improved pain and function. The evidence for many other interventions, including opioids, was limited. SN - 1538-3598 UR - https://www.unboundmedicine.com/medline/citation/34128998/Acute_Treatments_for_Episodic_Migraine_in_Adults:_A_Systematic_Review_and_Meta_analysis_ DB - PRIME DP - Unbound Medicine ER -