Background: While six triptans are available for migraine treatment in Canada, formulary listing varies by jurisdiction. To support the development of a consistent public policy, CADTH conducted a four-month review of the comparative clinical and cost-effectiveness of triptans in adults and adolescents. This presentation provides an overview of the results and limitations of this assessment and its potential contribution to decision making regarding migraine treatment.

Methods: To meet time constraints, a review by the Oregon Evidence-based Practice Center (DERP report) was chosen as the basis of the clinical review of triptan use in adults. A systematic review and meta-analysis was conducted to evaluate triptans in adolescents. Comparative cost-effectiveness was evaluated for adult and adolescent migraineurs.

Results: The DERP report, with minor flaws using the Oxman-Guyatt tool, suggests that while several head-to-head trials of triptans have been conducted in adults, few examine 24-hour sustained relief or long-term consistency. In adult migraineurs, studies of fair quality suggest rizatriptan is superior to sumatriptan or naratriptan for relieving pain at two hours, and sumatriptan is superior to naratriptan in relieving pain at four hours. It was not possible to determine the comparative efficacy of triptans in adolescents, as no head-to-head trials were found. A meta-analysis of two moderate-good quality trials suggests adolescents receiving sumatriptan nasal spray are 18% more likely to experience headache relief, 38% more likely to experience freedom from pain, and three times more likely to experience nausea, vomiting and taste disturbance than placebo recipients. Comparative cost-effectiveness studies were of limited utility to public healthcare decision makers, as they focused solely on drug costs and differed in their methods used to evaluate outcomes. Most economic studies didn't compare all triptans, or used effectiveness data from a meta-analysis of questionable quality, raising concerns regarding validity and applicability of results.

Conclusions: There is need for head-to-head comparison trials to evaluate long-term sustained relief and consistency. Measures should be taken to reduce selection bias and placebo effects in future clinical studies. Comparative cost-effectiveness studies would benefit from a sound clinical evidence base, including all triptans, and considering resource utilization, productivity loss, and adverse events management. This review does not address drug switching, early management, or drug pharmacokinetics. Policy makers must consider limitations in the current evidence when making coverage decisions.