This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
Researchers ranked oral treatments for migraine attacks in an analysis of 137 studies.
They found that:
- drugs called triptans (for instance sumatriptan) were more effective than other medicines
- non-steroidal anti-inflammatories (ibuprofen, for instance) were the next most effective group
- the newest medicines available (for instance, rimegepant) were less effective than non-steroidal anti-inflammatory drugs.
The researchers hope their findings will inform clinical guidelines and help with shared decision-making during consultations.
More information about migraine can be found on the NHS website.
The issue: what should I take for a migraine attack?
A migraine attack usually feels like a severe headache with throbbing pain on one side of the head. It often comes with other symptoms such as nausea. Attacks can last between 2 hours and 3 days; some people have attacks rarely while others might have several a week.
According to The Migraine Trust, in 2021 around 10 million adults in the UK were living with migraine. Around 43 million workdays are lost because of migraine every year, and the condition accounts for many (4%) primary care consultations.
The National Institute for Health and Care Excellence (NICE) recommends pain relief (such as ibuprofen or paracetamol) for migraine attacks, and where this is insufficient, add or replace with a triptan (for instance sumatriptan). But some people cannot take triptans (those at risk of cardiovascular or vascular diseases, for instance). In 2023, a newer drug (rimegepant) that could be used instead of triptans became available in the UK.
Most studies on the effectiveness of migraine drugs have been sponsored by the pharmaceutical industry. A network meta-analysis brings together many studies with different sponsors, which reduces the potential bias in findings. Researchers used this approach to explore which oral medicines were most effective for migraine attacks.
What’s new?
The analysis included 137 randomised controlled trials that, between them, included all drugs licenced for acute migraine in the UK and elsewhere. The trials included a total of 89,445 adults with migraine. The team conducted a network meta-analysis to rank all drugs, from different studies.
The researchers considered the immediate effect of a drug (freedom from pain 2 hours after taking it). In the 153 comparisons included, all active drugs were more effective than placebo (sugar pill).
The chance of being pain-free at 2 hours was:
- highest with most triptans (migraine-specific painkillers) such as eletriptan (37%) or sumatriptan (29%)
- slightly lower with non-steroid drugs that reduce inflammation such as diclofenac potassium (26%) or ibuprofen (20%)
- lowest with drugs that reduce temperature such as paracetamol (19%) or new migraine-specific painkillers ubrogepant (also 19%) or rimegepant (18%); naratriptan was similar (17%).
A second outcome (from 105 comparisons) was the impact of the drug over the course of the day. The study found that the chance of being pain-free 2-24 hours after taking a drug was:
- increased by most drugs (paracetamol and naratriptan performed the worst)
- most effectively increased by ibuprofen (38% chance) and eletriptan (26%).
Panels of patients and clinicians identified important side effects of drugs: chest pain, dizziness, fatigue, nausea, paraesthesia (pins and needles, or numbness of the skin), and sedation. The researchers found that:
- eletriptan was associated with more chest pain, dizziness and fatigue than other drugs; other triptans (sumatriptan and zolmitriptan) were associated with dizziness
- diclofenac potassium was associated with nausea
- ubrogepant was associated with chest pain.
Why is this important?
This study gives the most comprehensive analysis to date of the effectiveness of drugs for migraine. The findings on both benefits and harms should inform shared decision-making.
The results imply that triptans are the most effective treatments for migraine when people do not have certain other conditions. Triptans were more effective than newer and more expensive drugs such as rimegepant. The findings suggest that diclofenac potassium or ibuprofen might be the next best treatment when triptans are not suitable.
The studies included in the analysis varied in certainty. For the impact on pain at 2 hours, few (8%) studies were rated moderate certainty; 74% were very low certainty. For freedom from pain at 24 hours, most (90%) were very low certainty. More high-quality research is needed to evaluate drugs for migraine.
The analysis did not include studies that analysed drugs used in combination and only included drugs taken by mouth. The researchers did not account for clinical issues that might inform decision making, for instance headache caused by medication overuse.
What’s next?
Previous research has shown that even in wealthy countries, migraine-specific medications (including triptans) are underused. More research is needed to explore the safety of triptans in people with vascular disease and to determine the cost-effectiveness of medications.
The researchers hope their findings will inform future guidelines. They hope that triptans will be included in the WHO List of Essential Medicines to promote access to this effective treatment in all countries. The researchers have made their dataset freely and fully available for others to review.
You may be interested to read
This is a summary of: Karlsson WK, and others. Comparative effects of drug interventions for the acute management of migraine episodes in adults: systematic review and network meta-analysis. British Medical Journal 2024; 386: e080107.
Triptans found to be the most effective drug for acute migraine sufferers. A press release on this study from the University of Oxford Department of Psychiatry. 19 September 2024.
Information from The Migraine Trust.
An NIHR Evidence summary about what treatments are best for preventing migraine attacks.
Funding: This study was funded by the NIHR Oxford Health Biomedical Research Centre.
Conflicts of Interest: Several of the study authors have received funding from several pharmaceutical companies that produce migraine drugs. See paper for full details.
Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
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