Review of acute migraine treatment reveals many effective opioids that are unsuitable

Several pharmacological and non-pharmacological therapies were found to improve pain outcomes in adults with migraines, although the strength of the evidence to support these treatments varied according to the results of a systematic review and meta-analysis published in JAMA.

The aim of the study was to evaluate the benefits and risks of various acute treatments for episodic migraines. After an extensive literature search, independent reviewers identified and extracted data from 15 systematic reviews that analyzed evidence on triptans and nonsteroidal anti-inflammatory drugs (NSAIDs), as well as from 115 randomized clinical trials (n = 28,803) evaluating other interventions.

Pain relief, pain relief, persistent pain relief, and adverse events were the main outcomes of the study. The Agency for Healthcare Research and Quality Methods Guide for Effectiveness and Comparative Effectiveness Reviews was used to assess the strength of evidence (SOE).

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Compared to placebo, significant improvements in short-term pain outcomes were observed with triptans (high SOE), NSAIDs (moderate SOE), calcitonin gene-related peptide receptor antagonists (rimegepant, Ubrogepant; low to high SOE), lasmiditan (5-HT1F pain) receptor agonist; high SOE), dihydroergotamine (moderate to high SOE), ergotamine plus caffeine (moderate SOE), paracetamol (moderate SOE), antiemetics (chlorpromazine, prochlorperazine, metoclopramide, haloperidol, droperidol; low SOE), butorphanol (low SOE) and tramadol plus Acetaminophen (low SOE).

An increased risk of mild and transient side effects has been observed with triptans (e.g. malaise, nausea, chest pain, sensation of heat, palpitations, paresthesia) and NSAIDs (e.g. dyspepsia, nausea, drowsiness, dizziness). Ubrogepant was associated with significantly more ear, nose and throat symptoms, while the use of lasmiditan was associated with an increased risk of gastrointestinal and neurological side effects. Among the antiemetics, a significantly increased risk of adverse events was observed with haloperidol, droperidol and prochlorperazine. Gastrointestinal side effects have also been noted with the use of ergot alkaloid drugs.

Several non-pharmacological treatment options were associated with improvement in pain, including remote electrical neuromodulation (moderate SOE), transcranial magnetic stimulation (low SOE), external trigeminal stimulation (low SOE), and non-invasive vagus nerve stimulation (moderate SOE). No significant differences in side effects compared to Schein were observed.

“This review found that the overall SOE for opioids is low or inadequate, and opioids were associated with higher rates of side effects compared to other treatment options or placebo,” the authors say. “This means that the current guidelines against opioids are in place.”


VanderPluym JH, Halker Singh RB, Urtecho M, et al. Acute treatments for episodic migraines in adults: a systematic review and meta-analysis. JAMA. Published online June 15, 2021. doi: 10.1001 / jama.2021.7939

This article originally appeared on MPR

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