Economic comparison of oral triptans for management of acute migraine: implications for managed care

Sound, informed decision making regarding which drugs to include on a formulary should be based on the best available evidence of their clinical efficacy and incidence of adverse events. Comparative drug costs and clinical effectiveness should also be considered during the formulary development process. Clinical trials traditionally evaluate efficacy and adverse events independently, whereas effectiveness in real-life conditions is defined as some combination of efficacy and side effects. When evaluating similar medications, head-to-head efficacy and effectiveness studies are preferred. For oral triptans (serotonin 5-HT(1B,1D) receptor agonists), there are many placebo-controlled trials and several active trials that compare newer oral triptans with sumatriptan; however, there have been few comparisons of triptans in head-to-head trials. Meta-analysis is an appropriate method to evaluate multiple clinical trials critically and combine the results. A recently published meta-analysis used patient-level data to assess efficacy and adverse events across multiple triptan clinical trials. In this analysis, we combined those results with medication costs to assess the overall value among oral triptans. Using this combined approach, almotriptan was found to have the greatest economic value. It delivers comparable efficacy, placebo-like tolerability, and the highest value when compared with other triptans currently marketed in the United States.