Treating migraine attacks: new evidence to guide choices

Trust a doctor to put a dampener on things. Just imagine, there you are having visions where “Heaven was opened and a fiery light of exceeding brilliance came and permeated my whole brain, and inflamed my whole heart and my whole breast, not like a burning but like a warming flame, as the sun warms anything its rays touch.” This was the lot of a 12th century abbess, Hildegard von Bingen. According to neurologist Oliver Sacks, the poor dear was just experiencing migraines. Whether Hildegard was a migraine sufferer remains speculative and this could be a case of historical over diagnosis. I’m not convinced she would have wanted to put a stop to these experiences, but if you are prone to migraines I’m sure you’ll want to know what might work for you in stopping the severe headaches that is a key feature for most sufferers. Your GP will want to know too and the chances are you might be taking a medicine from the triptan family of drugs. A team of reviewers at the Cochrane Pain, Palliative and Supportive Care Group (PaPaS) has recently published evidence on two of these, which should be helpful to those making choices about treating migraine attacks.

What can help? Sumatriptan can!

The first of these is Sumatriptan, which you might take by mouth (oral), nasal spray (intranasal), injected under the skin (subcutaneous) or by suppository (rectal). The PaPaS reviewers have previously done four reviews, pulling together evidence on sumatriptan taken by each of these routes. They’ve now put these together in one overview, making it easier for us to see what’s what.  It’s great to know that, aside from a shortage of information about rectal sumatriptan, the evidence is excellent, so we can feel confident about the results. The trials were high quality and included over 50,000 people with migraine. They compared doses commonly prescribed in Europe and North America with placebo (fake medicine) or other medicines.

Here’s what they found:

  • Subcutaneous administration was the most effective, with pain reduced from severe/moderate to none 2 hours after a 6mg dose of sumatriptan in 6 out of 10 people, compared with 1 in 7 taking placebo. If two people are treated, one is likely to benefit
  • The most commonly used doses of oral, rectal, and intranasal sumatriptan also provided clinically useful pain relief
  • The least effective dose and route combinations was oral sumatriptan 50mg but even this provided complete pain relief ager 2 hours in 3 out of 10 people. One person should benefit for every six treated
  • Subcutanous sumatriptan gave the fastest pain relief
  • Taking sumatriptan early while the pain was still mild was more effective than waiting until it was moderate or severe
  • For relief from pain after 2 hours, the most effective doses for each route were oral 100mg, subcutaneous 6mg, intranasal 20mg and rectal 25mg
  • Adverse events (side effects) were generally mild or moderate and were more common with subcutaneous sumatriptan and with higher doses of oral and intranasal sumatriptan than with other dose and route combinations
  • Giving sumatriptan subcutaneously costs more than other methods
  • Oral sumatriptan was compared to other medicines and there was little difference between them, except for eletriptan (especially the 80mg dose) which gave better relief from pain and other headache-related symptoms
Three Days Dead by Suzanne Garnier

Three Days Dead by Suzanne Garnier
Migraine Masterpieces 2003 Winner
National Headache Foundation

So sumatriptan may well help you treat your migraine attacks. Which route of administration you try may depend on your preferences and what’s available, as well as a consideration of the evidence here about the strengths and weaknesses of the different routes. New ways to give it are currently being considered, including through the lining of the mouth, via a patch on the skin and with a needle-free injection system. For existing methods and doses, this review suggests that there’s scope for experimenting to see what works for you.

Zolmitriptan could work for you

Zolmitriptan might work for people who don’t find good migraine relief from sumatriptan, and vice versa. A Cochrane review on this drug for acute migraine attacks in adults has generally good quality evidence from randomised trials with over 20,000 people. It showed that:

  • Oral zolmitriptan 2.5 mg and 5 mg gave headache relief at two hours to the same proportion of people as oral sumatriptan 50 mg, although not necessarily the same individuals. There was no difference in numbers having side effects.
  • There was little difference in effectiveness between the 2.5mg and 5mg oral dose; both were consistently better than placebo. 10mg oral zolmitriptan was more effective than the lower doses
  • Side effects were mild and happened more as the dose increased

Getting it right for you

These reviews provide good evidence for the effectiveness of both these drugs and support for switching from one to the other, or a different route of administration, to find what works best for you. GPs may well start by prescribing the cheapest medicine that works for most people but will find good reason here not to restrict their prescribing to that.

There’s no evidence that Hildegard ever painted the strange illuminations which have led some to identify her as a likely migraineur; what we see in pictures like the one at the start of this blog show others’ ideas of what her visions were like. But art is a powerful means for people to communicate their migraine experiences. Do read my earlier blog, which tells the tale of a handsome stranger behind the concept of migraine art and gives you a summary of some more Cochrane evidence on medicines for migraine.

For more evidence on treating migraine and other types of pain, do also visit the Cochrane Pain, Palliative and Supportive Care Group’s website or follow them on Twitter @CochranePaPaS #PainEvidence

The featured image is from the Migraine Art collection, Migraine Action.


Derry CJ, Derry S, Moore RA. Sumatriptan (all routes of administration) for acute migraine attacks in adults – overview of Cochrane reviews. Cochrane Database of Systematic Reviews 2014, Issue 5. Art. No.: CD009108. DOI: 10.1002/14651858.CD009108.pub2. 

Cochrane summary:

Bird S, Derry S, Moore RA. Zolmitriptan for acute migraine attacks in adults. Cochrane Database of Systematic Reviews 2014, Issue 5. Art. No.: CD008616. DOI: 10.1002/14651858.CD008616.pub2.

Cochrane summary:

Quote from Hildegard von Bingen, Scivias, translated by Mother Columba Hart, O.S.B., and Jane Bishop. Found in this blog:

Treating migraine attacks: new evidence to guide choices by Sarah Chapman

is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International

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