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Karlsson WK, et al. Comparative effects of drug interventions for acute migraine. PMID 39293828

Scope

The analysis combined 137 double-blind randomized trials with 89,445 participants and compared 17 licensed oral monotherapies for acute migraine.

Quantitative anchors

  • Every included active drug beat placebo for two-hour pain freedom.
  • Odds ratios versus placebo ranged from 1.73 (95% CI 1.27–2.34) for naratriptan to 5.19 (4.25–6.33) for eletriptan.
  • Eletriptan exceeded other active treatments in network contrasts with odds ratios ranging from 1.46 to 3.01; rizatriptan, sumatriptan and zolmitriptan also ranked highly.

Interpretation

Older triptans remain highly effective on average. Newer gepants and lasmiditan add options where vasoconstriction, tolerability or prior failure matters; novelty is not synonymous with greater mean efficacy.

Limitations

  • Network comparisons rely on transitivity across trials conducted in different eras and populations.
  • Single-attack endpoints do not fully capture consistency, recurrence or within-person preference.
  • Route, timing, contraindications, adverse events and access can outweigh mean ranking.
  • Certainty ranged from high to very low across comparisons.

Knowledge-base use

Anchors the acute-treatment hierarchy and supports a measured comparison rather than class-wide adjectives.