Drug treatments for migraines in adults
A systematic review/meta-analysis of oral drug therapies for the acute management of migraine in adults was recently published in the BMJ (184 RCTs/n=92,583 for the systematic review and 137 RCTs/n=89,445 for the network meta-analysis).
Findings
- Eletriptan, rizatriptan, sumatriptan, and zolmitriptan were found to perform best overall, when tolerability and efficacy were both taken into account.
- They were more effective than lasmiditan, rimegepant, and ubrogepant — their efficacy was shown to be comparable to most NSAIDs and paracetamol.
- The most efficacious treatments were eletriptan and ibuprofen for sustained pain relief up to 24 hours.
Bottom Line
- Triptans showing the most effectiveness should be preferred for acute treatment in migraine cases, though use in patients with a high-risk cardiovascular profile requires careful consideration, and cost effectiveness analyses are needed.
Further information on the pharmacological treatment of migraine in adults can be found in the 2022 module Headaches in Adults. Sumatriptan was listed as likely the most efficacious triptan at 2 hours post-treatment, though it was stated that few head-to-head comparisons of triptans had been conducted at that time.
Evidence snapshots: COVID-19
Nirmatrelvir/Ritonavir (Paxlovid) for Mild/Moderately Severe COVID-19
- All studies included in the review involved adults (≥ 18 years). The studies analysed included 4 RCTs (1 listed as low risk of bias, and 3 unclear risk of bias; n=4,070) and 16 real-world studies (all good quality; n=1,925,047).
- When compared to placebo, nirmatrelvir/ritonavir significantly reduced COVID-19 hospitalization, however, no significant difference was found for decrease in the following outcomes: all-cause mortality, viral clearance, worsening severity, adverse events, and serious adverse events. Trial sequential analysis suggested that conclusions could not be drawn based on the current total sample sizes for the aforementioned outcomes. Significantly reduced COVID-19 hospitalization and all-cause mortality was shown in real-world studies for nirmatrelvir/ritonavir compared to no treatment.
- The authors conclude that the nirmatrelvir/ritonavir approved treatment should be regarded as an experimental treatment for COVID-19, as opposed to a definitive antiviral pharmacological treatment.
Incidence of diabetes after SARS-CoV-2 infection in England and the implications of COVID-19 vaccination: a retrospective cohort study of 16 million people
- An investigation of the association between COVID-19 and the incidence of diabetes (type 1, type 2, gestational, and non-specific), along with the effect of COVID-19 vaccination, to 52 weeks post-diagnosis, was conducted using linked electronic health records of adults (18 to 110 years) registered with a family physician ≥ 6 months before baseline.
- An elevated incidence of type 2 diabetes following COVID-19 infection was found in patients hospitalized with COVID-19 when compared to those who were not hospitalized.
- The incidence of type 2 diabetes post-infection was markedly less apparent in vaccinated patients.
- The authors recommend considering routine testing for diabetes after a case of severe COVID-19, especially in patients who are an elevated risk of developing diabetes, and they recommended promoting vaccination.
Patients with type 1 diabetes are at elevated risk of developing new hypertension, chronic kidney disease and diabetic ketoacidosis after COVID-19
- Data from a health system in the Bronx, New York were analysed for three categories of patients with type 1 diabetes (T1D): those hospitalized for COVID-19 (n=511), those with a positive diagnosis but not hospitalized (n=306), and T1D patients with no record of a positive COVID-19 test (n=1,547).
- Compared with T1D patients without a history of COVID-19, T1D patients who survived COVID-19 were found to have a greater risk of developing new chronic kidney disease, hypertension, and diabetic ketoacidosis up to 40 months post-infection.
- Study limitations noted by the authors included the possibility that some patients listed as not having COVID-19 may have been misclassified if they did not have a registered positive test on record with the studied health system. Also, as this retrospective study used data from one system within the Bronx, it may not be appropriate to generalize the results to other populations which are less diverse. The studied patient population had high percentages of minority groups and lower socioeconomic status.