Migraine league table from a systematic review

Clinical bottom line

A systematic review of triptans in acute migraine from Canada gives a league table for headache response and pain free outcomes at two hours.

Reference

MJ Gawel et al. A systematic review of the use of triptans in acute migraine. Canadian Journal of Neurological Science 2001 28: 30-41.

Review

This review sought to consolidate evidence for triptans available in Canada. That point is important, since the review is not comprehensive and some doses of some triptans are not reviewed. Otherwise randomised full publications of trials of triptans in migraine were sought using MEDLINE. It is not stated what the inclusion criteria were, but the trials were commercial phase 3 trials, which were double blind, and used IHS criteria for definition of migraine.

The outcomes sought were headache response at one or two hours, pain free at one or two hours, and a clinical disability score of 0 or 1 at two hours. Oral rizatriptan did not include buccal wafers, which were analysed separately from a single trial.

Results

Only the two hour results are discussed here. At one hour there was less effect ( see rizatriptan review ), but the relative positions of treatments was similar.

Headache response at two hours

For headache initially moderate or severe to disappear or be only mild at two hours, results are shown in Table 1, In Figure 1 for the NNTs and in Figure 2 for the percentage of patients benefiting. Clearly subcutaneous sumatriptan was superior, but of the oral triptans rizatriptan 10 mg was the best.

Note that treatments are comparable, with similar response rates in the placebo groups.

Table 1: Headache response at two hours

				Percent responding to
Treatment	Route	Number of trials	Number of patients	Treatment	Placebo	NNT (95%CI)
Sumatriptan 6 mg	Subcut	5	818	71	21	2.0 (1.8 to 2.3)
Rizatriptan 10 mg	Oral	6	2797	74	28	2.2 (1.8 to 2.7)
Sumatriptan 50 mg	Oral	3	927	65	31	3.0 (2.5 to 3.7)
Sumatriptan 100 mg	Oral	12	2914	57	25	3.1 (2.8 to 3.4)
Sumatriptan 20 mg	Intranasal	5	1266	63	34	3.5 (3.0 to 4.3)
Zolmitriptan 2.5 mg	Oral	2	651	64	35	3.5 (2.7 to 4.7)
Naratriptan 2.5 mg	Oral	2	1437	47	28	5.1 (4.1 to 6.7)

Figure 1: NNT for headache response at 2 hours

Figure 2: Percentage of patients with headache response at 2 hours (95% confidence interval

Pain free at two hours

For headache initially moderate or severe to disappear and for patients to be pain free at two hours, results are shown in Table 2, In Figure 3 for the NNTs and in Figure 4for the percentage of patients benefiting. Clearly subcutaneous sumatriptan was superior, but of the oral triptans rizatriptan 10 mg was the best.

Note that treatments are comparable, with similar response rates in the placebo groups. For sumatriptan 6 mg subcutaneous there were only 110 patients in a single trial, so that placebo comparisons are not sensible.

Table 2: Pain free at two hours

				Percent responding to
Treatment	Route	Number of trials	Number of patients	Treatment	Placebo	NNT (95%CI)
Sumatriptan 6 mg	Subcut	1	110	55	17	2.6 (1.8 to 4.8)
Rizatriptan 10 mg	Oral	6	2797	40	8	3.2 (2.9 to 3.5)
Sumatriptan 50 mg	Oral	2	834	35	9	3.9 (3.2 to 4.9)
Sumatriptan 100 mg	Oral	6	1500	28	8	4.9 (4.1 to 5.9)
Zolmitriptan 2.5 mg	Oral	2	651	25	8	5.9 (4.5 to 8.7)
Naratriptan 2.5 mg	Oral	2	1437	23	8	6.5 (5.3 to 8.5)

Figure 3: NNT for pain free at 2 hours

Figure 4: Percentage of patients with headache response at 2 hours (95% confidence interval

Clinical disability at two hours

This refers to patients who had a disability score of 0 or 1 at two hours. The results are shown in Table 3, but note the very wide differences in the rates obtained with placebo, making comparison between treatments suspect. It may actually make the outcome itself unreliable, but as no details were given of what actual outcome was used in each of the trials, it is difficult to comment.

Table 3: Clinical disability at two hours

				Percent responding to
Treatment	Route	Number of trials	Number of patients	Treatment	Placebo	NNT (95%CI)
Sumatriptan 6 mg	Subcut	3	268	72	30	2.3 (1.9 to 3.1)
Rizatriptan 10 mg	Oral	5	2040	44	17	3.7 (3.2 to 4.3)
Sumatriptan 100 mg	Oral	6	1269	38	19	5.4 (4.3 to 7.4)
Sumatriptan 20 mg	Intranasal	3	1116	72	52	4.9 (3.8 to 7.0)
Sumatriptan 50 mg	Oral	4	1271	42	24	5.3 (4.1 to 7.5)
Naratriptan 2.5 mg	Oral	2	1437	66	48	5.6 (4.3 to 7.7)

Comment

This is a valuable study, despite not comprehensively covering all the doses of all the triptans. The information here agrees well with that in other systematic reviews, and for headache response at two hours summarised in a larger assessment of relative efficacy .