Newer Migraine Drugs Offer No Clinically Important Advantage, ACP Guideline Reports
A new clinical guideline from the American College of Physicians (ACP) advises monotherapy for episodic migraine prevention in nonpregnant adults in the outpatient setting. The guideline, published in the Annals of Internal Medicine, provides 3 specific recommendations for clinicians.
The first recommendation calls for choosing one of several pharmacologic treatment options: a beta-adrenergic blocker, either metoprolol or propranolol; the antiseizure medication valproate; the serotonin and norepinephrine reuptake inhibitor venlafaxine; or the tricyclic antidepressant amitriptyline.
If the treatment in the first recommendation cannot be tolerated or leads to inadequate response, the second recommendation advises monotherapy with a calcitonin gene-related peptide (CGRP) antagonist (atogepant or rimegepant) or a CGRP monoclonal antibody (eptinezumab, erenumab, fremanezumab, or galcanezumab).
If the patient still cannot tolerate treatment or shows an inadequate response, the third recommendation suggests monotherapy with the antiseizure medication topiramate.
The ACP Clinical Guidelines Committee (CGC) used the Grading of Recommendations Assessment, Development, and Evaluation approach to assess findings for a slate of clinical outcomes from a comparative effectiveness systematic review of pharmacologic treatments for episodic migraine prevention. Data on adverse events from drug labels and studies was also examined.
According to the guideline, however, there appeared little difference in clinical net benefit across treatments.
Subsequently, “[t]he CGC used economic evidence and data on patients’ values and preferences as primary factors in its rationale for clinical recommendations because the relative net benefit of the recommended treatments for the prevention of episodic migraine headache did not clearly favor any treatment over another,” wrote corresponding author Amir Qaseem, MD, PhD, MHA, of the American College of Physicians, Philadelphia, Pennsylvania, and coauthors of the guideline.
While cost was a key consideration in prioritizing the recommended treatments in the guideline, actual costs for patients may vary, the committee noted.
“Therefore,” the authors advised, “it is important to carefully assess each person’s economic circumstances and personal preferences during the decision-making process when choosing the most appropriate treatment.”
