Triptans for Acute Migraine: Comparative Clinical Effectiveness and Cost-effectiveness

Technology and Condition

Serotonin receptor (5HT1) agonists (triptans):almotriptan, eletriptan, naratriptan, sumatriptan succinate/hemisulfate, rizatriptan, and zolmitriptan fortreatment of acute migraine in adults and adolescents

Issue

Acute migraine is associated with significant costs to public payers and society. The use of triptan therapy may lead to improved quality of life, and the cost of therapy may be offset by savings associated with reduction in need for healthcare services and increased productivity. Public funding policies across Canada are inconsistent.

Methods and Results

A systematic review was summarized and appraised to compare triptans in adults. A systematic review of the clinical literature was performed to compare triptans in adolescents. A systematic review of economic evaluations was conducted to identify the primary influential factors determining the cost-effectiveness of therapy, and identify compelling evidence of cost effectiveness in a Canadian population.

Implications for Decision Making

Differences across all triptans have not been demonstrated in adults. No trials were identified that directly compared all available triptans with each other. Instead, most of the evidence suggesting comparative differences in effectiveness are from trials comparing one triptan with sumatriptan. There was no evidence to suggest individuals could be identified who would benefit from a particular triptan versus anyother. More comparisons among triptans are required to establish overall differences
The generalizability of clinical evidence to current practice requires consideration. None of the RCTsidentified investigated the effect of triptan use for early treatment or mild migraine, although this is commonly encouraged in current practice. This practice could change the magnitude of observed responses from that seen in clinical trials. Switching to a different triptan, rather than continuing with the same triptan, is encouraged in current practice and may result in different success measures than that observed in clinical trials
Naratriptan may require special consideration in adults. There is fair evidence to suggest that rizatriptan10 mg is superior to naratriptan 2.5 mg in relieving headache pain, photophobia, and phonophobia at two hours, and providing sustained relief at 24 hours. Fair evidence suggests that sumatriptan 100 mg is superior tonaratriptan 2.5 mg for relieving headache pain at four hours. Because these differences were demonstrated by one trial for each comparison, decisions regarding naratriptan should be reconsidered as new information becomes available
Nasal sumatriptan requires consideration in adolescents. The evidence of effectiveness in adolescents was derived from eight RCTS comparing five triptans to identical placebos. Only sumatriptan 20 mg nasal spray significantly increased the likelihood of a two-hour response, with the combined results of two trials suggesting a number needed-to-treat of 10 (95% CI: 6, 36).The combined response of sumatriptan recipients from both trials showed a 38% response rate for achieving freedom from pain at two hours, with a number needed-to treatof 10 (95% CI: 6, 30]
No compelling economic evidence supporting one triptan over any other could be identified. Only two of the 12 identified economic evaluations incorporated utility into their analyses. Neither study compared all available triptans or used credible estimates of effectiveness. Most cost-effectiveness evaluations harboured flaws, such as failure to identify major costs and benefits or resource use. Given their limitations, the applicability of these studies to Canadian decision makers remains questionable

This summary is based on a rapid review assessment available from CADTH’s web site (www.cadth.ca): Member S, McGahan L, Cimon K,Gawel M, Giammarco R, Mierzwinski-Urban M. Triptans for acute migraine: comparative clinical effectiveness and cost-effectiveness.