Sumatriptan (all routes of administration) for acute migraine attacks in adults - overview of Cochrane reviews

  • Review
  • Overview

Authors

  • Christopher J Derry,

    1. University of Oxford, Pain Research and Nuffield Department of Clinical Neurosciences, Oxford, Oxfordshire, UK
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  • Sheena Derry,

    Corresponding author
    1. University of Oxford, Pain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics), Oxford, Oxfordshire, UK
    • Sheena Derry, Pain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics), University of Oxford, Pain Research Unit, Churchill Hospital, Oxford, Oxfordshire, OX3 7LE, UK. sheena.derry@ndcn.ox.ac.uk.

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  • R Andrew Moore

    1. University of Oxford, Pain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics), Oxford, Oxfordshire, UK
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Abstract

Background

Migraine is a highly disabling condition for the individual and also has wide-reaching implications for society, healthcare services, and the economy. Sumatriptan is an abortive medication for migraine attacks, belonging to the triptan family. It is available for administration by four different routes: oral, subcutaneous, intranasal, and rectal.

Objectives

To summarise evidence from four Cochrane intervention reviews on the efficacy and tolerability of sumatriptan in the treatment of acute migraine attacks in adults by four routes of administration (oral, subcutaneous, intranasal, and rectal) compared with both placebo and active comparators.

Methods

The included reviews were written by the authors of this overview; no additional searching was carried out. All included reviews were conducted according to a standard protocol and reported a standard set of outcomes. From each individual review we extracted results for pain relief at different levels, and adverse events. No additional statistical comparison was undertaken as part of the overview. We focused on the most important findings for doses and routes licensed in North America or Europe (oral 25 mg, 50 mg, 100 mg; subcutaneous 4 mg, 6 mg; intranasal 5 mg, 10 mg, 20 mg; rectal 25 mg).

Main results

Included reviews provided data for 18 different dose and route of administration combinations in 52,236 participants. Data for the primary outcomes sought were generally well reported, and involved adequate numbers of participants to give confidence in the results, except for the rectal route of administration, where numbers were low.

Subcutaneous administration was the most effective, with pain reduced from moderate or severe to none by two hours in almost 6 in 10 people (59%) taking 6 mg sumatriptan, compared with approximately 1 in 7 (15%) taking placebo; the number needed to treat (NNT) was 2.3 (95% confidence interval 2.1 to 2.4) with 2522 participants in the analysis. The most commonly used doses of oral, rectal, and intranasal sumatriptan also provided clinically useful pain relief, with the oral 50 mg dose providing complete relief of pain in almost 3 in 10 people (28%) compared with about 1 in 10 (11%) after placebo (NNT 6.1 (5.5 to 6.9) in 6447 participants). Subcutaneous administration provided more rapid pain relief than the other routes. Taking medication early, when pain was mild, was more effective than waiting until the pain was moderate or severe.

The most effective dose of sumatriptan for each route of administration for the outcome of headache relief (pain reduced from moderate or severe to none or mild) at two hours was oral 100 mg (NNT 3.5 (3.2 to 3.7) in 7811 participants), subcutaneous 6 mg (NNT 2.1 (2.0 to 2.2) in 2738 participants), intranasal 20 mg (NNT 3.5 (3.1 to 4.1) in 2020 participants), and rectal 25 mg (NNT 2.4 (1.9 to 3.4) in 240 participants).

Adverse events were generally of mild or moderate severity, of short duration, and more common with subcutaneously administered sumatriptan and higher doses of oral and intranasal sumatriptan than with other dose and route combinations.

Authors' conclusions

Sumatriptan is an effective abortive treatment for acute migraine attacks, but is associated with increased adverse events relative to placebo. The route of administration influences efficacy, particularly within the first hour after administration. Subcutaneous sumatriptan shows the greatest efficacy in terms of pain relief, but at the expense of relatively high levels of adverse events, and with a high financial cost compared with other routes. Information about the relative efficacy of the different routes of administration for different outcomes should help to inform decisions about the suitability of sumatriptan as a migraine treatment, as well as about the most appropriate way to administer the treatment for individual patients.

Plain language summary

Sumatriptan (all routes of administration) for acute migraine attacks in adults

Migraine is a complex condition with a wide variety of symptoms. For many people, the main feature is a painful, and often disabling, headache. Other symptoms include disturbed vision; sensitivity to light, sound, and smells; feeling sick; and vomiting. Migraine affects about 1 person in 8, mainly women, and mainly in the age range of 30 to 50 years.

Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It can be given by four different routes: by mouth (oral), by injection under the skin (subcutaneous), by nasal spray (intranasal), and by suppositories (rectal). Separate Cochrane reviews for each of these routes provided information on how well sumatriptan worked at reducing headache pain in over 50,000 people with migraine. For oral, subcutaneous, and intranasal sumatriptan there was a large amount of information from good quality trials, but there was relatively little information about rectal administration.

This overview found that a single dose administered via any of these routes was effective in relieving migraine headache pain.

The subcutaneous route provided the best pain relief, with pain reduced from moderate or severe to none by two hours in almost 6 in 10 people (59%) taking the 6 mg dose, compared with approximately 1 in 7 (15%) taking placebo. The most commonly used doses of oral, rectal, and intranasal sumatriptan also provided useful pain relief. The oral 50 mg dose (the least effective of the commonly used dose and route combinations) provided complete relief of pain in almost 3 in 10 people (28%) compared with about 1 in 10 (11%) after placebo. Subcutaneous sumatriptan was also the fastest acting, providing more people with pain relief within one hour of treatment than any other route of administration.

Adverse events, which were mostly of mild or moderate severity and of short duration, were more common with subcutaneously administered sumatriptan and higher doses of oral and intranasal sumatriptan than with other dose and route combinations.

Laički sažetak

Sumatriptan (svi načini primjene) za akutne migrenske napade u odraslih: pregled svih Cochrane sustavnih pregleda na tu temu

Migrena je složeno stanje koje može uzrokovati različite simptome. Kod mnogih je pacijenata glavno obilježje migrene bolna glavobolja koja često onemogućuje uredno funkcioniranje. Ostali simptomi uključuju poremećeni vid, osjetljivost na svjetlo, zvukove i mirise, osjećaj mučnine i povraćanje. Migrena pogađa otprilike jednu na osam osoba, uglavnom žene, najčešće u dobi od 30 do 50 godina.

Sumatriptan pripada skupini lijekova triptani koji se koriste u terapiji migrenskih napada. Može se primijeniti na četiri različita načina: na usta (oralno), injekcijom pod kožu (subkutano), sprejem za nos (intranazalno) i pomoću supozitorija (rektalno). Zasebni Cochrane sustavni pregledi svakog od ovih načina primjene daju informacije o tome koliko je sumatriptan učinkovit u ublažavanju glavobolje na preko 50.000 osoba s migrenom. Za oralno, subkutano i intranazalno primjenjen sumatriptan pronađena je velika količina podataka iz studija dobre kvalitete, ali za rektalnu primjenu je bilo relativno malo podataka.

Ovaj pregled pronašao je da je jedna doza lijeka primijenjena bilo kojim načinom bila učinkovita za smanjenje migrenske glavobolje.

Subkutani način primjene pružio je najbolje smanjenje boli, s ublažavanjem boli od umjerene ili jake do nikakve nakon dva sata u gotovo 6 od 10 osoba (59%) koje su uzimale dozu od 6 mg, u usporedbi s otprilike 1 od 7 osoba koje su uzimale placebo. Najčešće primjenjivane doze oralno, rektalno i intranazalno primjenjenog sumatriptana također su omogućile dovoljno ublažavanje boli. Oralna doza od 50 mg (najmanje učinkovita od svih uobičajenih kombinacija doza i načina primjene) omogućila je potpuno uklanjanje boli u gotovo 3 od 10 osoba (28%) u usporedbi s oko 1 od 10 (11%) nakon placeba. Subkutano primijenjeni sumatriptan je najbrže djelovao, pružajući uklanjanje boli unutar sat vremena od uzimanja za više ljudi od ostalih načina primjene.

Nuspojave, koje su većinom bile blage ili umjerene težine i kratkog trajanja, bile su češće kod subkutano primjenjenog sumatriptana i viših doza oralnog i intranazalnog sumatriptana nego kod drugih kombinacija doze i načina primjene.

Bilješke prijevoda

Hrvatski Cochrane
Preveo: Adam Galkovski
Ovaj sažetak preveden je u okviru volonterskog projekta prevođenja Cochrane sažetaka. Uključite se u projekt i pomozite nam u prevođenju brojnih preostalih Cochrane sažetaka koji su još uvijek dostupni samo na engleskom jeziku. Kontakt: cochrane_croatia@mefst.hr