A large study into the effectiveness of migraine medications has found that some well-established, cheaper medications are just as effective at preventing migraines as the first-line treatment or newer, more expensive drugs. The findings provide options to migraine sufferers who might be struggling to find, or fund, an effective treatment.
More than a headache, migraines can cause painful throbbing or pulsing on one side of the head and are often accompanied by disabling nausea, vomiting, and sensitivity to light and/or sound. Medications used to treat migraines are either abortives, used to treat acute symptoms, or preventives, which reduce the frequency, intensity, and duration of migraine attacks.
Preventive migraine medications include older generic drugs like beta-blockers, antidepressants, and anticonvulsants. Newer preventives include calcitonin gene-related peptide pathway monoclonal antibodies (CGRP mABs) and botulinum toxin A (BtA or Botox) for chronic migraine. People with chronic migraines, compared to those who have episodic attacks, require considerable pharmacotherapy support, which can have a significant financial impact.
In a new study, researchers from the University of Bergen, Norway, examined the real-world use of migraine preventive drugs to determine treatment duration and effectiveness by looking at how often a person filled their triptan prescription, a drug used to treat acute migraine symptoms, after taking preventives.
Triptans are a class of medications used to alleviate the symptoms of acute migraine attacks. They’re not preventatives, nor are they analgesics; they bind to serotonin receptors in the brain, which reduces blood vessel swelling and inflammation. Commonly prescribed triptans include sumatriptan (Imitrex, Onzetra, Tosymra), rizatriptan (Maxalt), and zolmitriptan (Zomig).
“When the withdrawal of acute migraine medicines changed little after starting preventive medicines, or people stopped quickly on the preventive medicines, the preventive medicine was interpreted as having little effect,” said Marte-Helene Bjørk, lead and corresponding author of the study. “If the preventive medicine was used on long, uninterrupted periods, and we saw a decrease in the consumption of acute medicines, we interpreted the preventive medicine as having good effect.”
The researchers used data from the Norwegian Prescription Database about 104,072 migraine patients, 78.7% of whom were female, who filled prescriptions for migraine preventive drugs between 2010 and 2020. The primary outcomes were retention rate and effectiveness for the following drugs: beta-blockers (propranolol and metoprolol), candesartan, lisinopril, topiramate, CGRP mABs, BtA, clonidine, and simvastatin. These drugs are recommended for migraine prophylaxis or commonly used for this purpose.
Retention rates were defined as the duration, in days, of uninterrupted treatment periods. Effectiveness was defined as a reduction in triptan use over 360 days, divided into 90-day periods, after initiating a migraine preventive drug compared to triptan use before commencing that drug. In each successive 90-day period, only patients who hadn’t discontinued treatment were included in the calculation of effectiveness. Beta-blockers were selected as the active comparator for retention and effectiveness as they’re the most commonly prescribed first-line medication for migraine prophylaxis.
The researchers found that retention rates and effectiveness varied substantially across the drug groups. One year after the first prescription, the highest proportion of patients were on BtA (38.98%), CGRP mABs (31.43%), and simvastatin (21.97%). The proportion was lowest for clonidine (1.71%), topiramate (9.14%), and amitriptyline (10.34%).
For all drugs combined, 50.22% of patients achieved a 30% or greater reduction in triptan use during the 90 days following their first prescription. During this period, the proportion with a 30% or greater reduction was the largest for simvastatin (56.71%), CGRP mABs (54.71%), and amitriptyline (53.29%), with patients filling prescriptions for these drugs more likely to achieve a 30% triptan reduction than patients filling prescriptions for beta-blockers.
“[Amitriptyline and simvastatin] are also established medicines used for depression, chronic pain and high cholesterol, respectively, while CGRP inhibitors are developed and used specifically for chronic migraine,” said Bjørk.
Simvastatin was associated with higher effectiveness and retention than beta-blockers, whereas amitriptyline use was associated with lower retention than beta-blockers but higher effectiveness during the first 90 days of treatment. BtA was associated with the highest treatment retention of all preventive drugs, but the proportion of patients with reduced triptan use was lower for BtA than for beta-blockers.
While CGRP mABs were associated with higher retention and higher effectiveness than beta-blockers, baseline triptan use was considerably higher for patients taking this preventive treatment. Given the high cost of CGRP mABs, the researchers say their findings show that there are well-established, cheaper migraine preventives available that are just as effective.
“Our analysis shows that some established and cheaper medicines can have a similar treatment effect as the more expensive ones,” said Bjørk.
The researchers note the limitations of their study. Notably, comparing triptan use before and after starting a migraine preventive drug is an indirect measure of the number of migraine days. Also, tThe effect of preventive drugs on the use of non-specific acute drugs wasn’t assessed, and some drugs were not included because they weren’t approved as migraine preventives in Norway during the study period.
They've already commenced a large clinical study to measure the effect of established cholesterol-lowering medications as a preventive measure against chronic and episodic migraines.
The study was published in the European Journal of Neurology.
Source: University of Bergen
