Network meta-analysis of migraine therapies: balancing efficacy and safety

Migraine is a common and debilitating neurological condition, affecting roughly 10 % of the global population and placing a significant burden on public health. It occurs in episodes, often characterized by intense headaches accompanied by sensitivity to light (photophobia), sensitivity to sound (phonophobia), and a range of autonomic and sensory disturbances.

A comprehensive search of three databases was conducted up to April 30, 2023. A frequentist network meta-analysis was utilized to estimate both direct and indirect effects across six outcomes. Interventions were ranked independently for each outcome using the p-score. The choice of meta-analysis model was based on the I² statistic: a random-effects model was applied when I² exceeded 30 %, while a fixed-effect model was used when I² was ≤30 %. All statistical analyses were performed using R version 4.3.2.

A total of 80 articles were included in current investigation. For change in mean migraine days (MMD) as direct estimate, by taking placebo as reference treatment, suggested statistically significant result for CGRP (Calcitonin Gene-Related Peptide) receptor antagonist [SMD: -0.38 (-0.61, -0.14)], and CGRP mAbs [SMD: -0.35 (-0.41, -0.31)]. The maximum p-score was obtained by CGRP antagonist (0.71). Similarly, direct estimates were calculated for other outcomes of interest. Additionally, the indirect estimates were calculated taking all treatments under investigations as reference treatment, simultaneously, for each outcome of interest.

A network meta-analysis of migraine treatments found Triptans to be highly effective for pain, photophobia, phonophobia, and nausea relief, though with a higher risk of adverse events. CGRP antagonists excelled at reducing monthly migraine days but also had increased side effects.