Acute treatments for episodic migraine in adults: a systematic review and meta-analysis. VanderPluym JH, Halker Singh RB, Urtecho M, et al.The American Headache Society position statement on integrating new migraine treatments into clinical practice. The prevalence and impact of migraine and severe headache in the United States: figures and trends from government health studies. Agency for Healthcare Research and Quality December 2020. (Prepared by the Mayo Clinic Evidence-based Practice Center under contract no. Halker Singh RB, VanderPluym JH, Morrow AS, et al. Physicians should consider individual patient factors and access to medication when evaluating treatment choices after NSAIDs and triptans. If NSAIDs and triptans are ineffective or contraindicated, there are multiple options with moderate- to high-quality evidence of effectiveness including dihydroergotamine, antiemetics, acetaminophen, rimegepant, ubrogepant, and lasmiditan. Because many studies included in the systematic reviews of NSAIDs and triptans compared antiemetics in combination with NSAIDs or triptans, using a combination of NSAIDs and/or triptans with antiemetics would be reasonable. 10 In cases where NSAIDs or triptans are not effective or only partially effective, a trial of combination therapy would be appropriate. 4, 9 One important exception to this guidance is pregnancy, during which acetaminophen is the preferred pharmacologic choice. The review supports the guidance that physicians should use NSAIDs for acute treatment of mild or moderate migraines and triptans for treatment of moderate or severe migraines. More pain relief at 1 day RR = 3.06 (1.11 to 8.44) More pain relief at 2 hours RR = 3.86 (2.11 to 7.07) More total adverse events RR = 3.30 (1.76 to 6.17) More pain relief at 2 hours RR = 2.14 (1.16 to 3.96) More restored function at 1 week RR = 1.49 (1.04 to 2.13) No difference in restored function at 2 hours More total adverse events RR = 2.67 (2.10 to 3.39) More restored function at 2 hours RR = 1.42 (1.26 to 1.61) More pain relief at 2 hours RR = 1.38 (1.14 to 1.68) More pain relief at 2 hours RR = 1.21 (1.12 to 1.31) Improved function at 2 hours RR = 1.26 (1.12 to 1.42) More total adverse events RR = 1.23 (1.00 to 1.50) More restored function at 2 hours RR = 1.43 (1.26 to 1.62) More pain relief at 1 week RR = 1.64 (1.40 to 1.93) More pain relief at 2 hours RR = 1.36 (1.26 to 1.46) More total adverse events RR = 6.48 (1.49 to 28.17) More pain relief at 2 hours RR = 1.80 (1.10 to 2.94) More pain relief at 2 hours RR = 1.91 (1.47 to 2.48) More total adverse events RR = 6 (2.12 to 120.65) More total adverse events RR = 1.61 (1.18 to 2.20) More pain relief at 2 hours RR = 1.39 (1.11 to 1.74) More pain relief at 2 hours RR = 1.61 (1.05 to 2.49) More pain relief at 1 week RR = 1.48 (1.22 to 1.80) More pain relief at 2 hours RR = 1.83 (1.58 to 2.13) More restored function at 2 hours RR = 1.80 (1.27 to 2.54) More pain relief at all time points NNT < 10 in every systematic review 1 (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) Acupuncture does not relieve migraine pain compared with sham acupuncture, but noninvasive vagus nerve stimulation and remote electrical neuromodulation relieve acute migraine pain compared with sham stimulation. (SOR: A, based on consistent, good-quality patient-oriented evidence.) Opioids do not improve pain or function, and adverse events are greater, compared with established migraine treatment options. (SOR: A, based on consistent, good-quality patient-oriented evidence.) Calcitonin gene-related peptide antagonists and lasmiditan improve pain and function in acute migraines compared with placebo. (Strength of Recommendation : A, based on consistent, good-quality patient-oriented evidence.) Acetaminophen and dihydroergotamine also relieve migraine pain better than placebo. Nonsteroidal anti-inflammatory drugs (NSAIDs) and triptans, individually and combined, are superior compared with placebo in resolving episodic migraine pain and are first-line choices for acute treatment.
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