Objective To compare all licensed drug interventions as oral monotherapy for the acute treatment of migraine episodes in adults. Design Systematic review and network meta-analysis. Data sources Cochrane Central Register of Controlled Trials, Medline, Embase, ClinicalTrials.gov, EU Clinical Trials Register, WHO International Clinical Trials Registry Platform, as well as websites of regulatory agencies and pharmaceutical companies without language restrictions until 24 June 2023. Methods Screening, data extraction, coding, and risk of bias assessment were performed independently and in duplicate. Random effects network meta-analyses were conducted for the primary analyses. The primary outcomes were the proportion of participants who were pain-free at two hours post-dose and the proportion of participants with sustained pain freedom from two to 24 hours post-dose, both without the use of rescue drugs. Certainty of the evidence was graded using the confidence in network meta-analysis (CINeMA) online tool. Vitruvian plots were used to summarise findings. An international panel of clinicians and people with lived experience of migraine co-designed the study and interpreted the findings. Eligibility criteria for selecting studies Double blind randomised trials of adults (≥18 years) with a diagnosis of migraine according to the International Classification of Headache Disorders. Results 137 randomised controlled trials comprising 89 445 participants allocated to one of 17 active interventions or placebo were included. All active interventions showed superior efficacy compared with placebo for pain freedom at two hours (odds ratios from 1.73 (95% confidence interval (CI) 1.27 to 2.34) for naratriptan to 5.19 (4.25 to 6.33) for eletriptan), and most of them also for sustained pain freedom to 24 hours (odds ratios from 1.71 (1.07 to 2.74) for celecoxib to 7.58 (2.58 to 22.27) for ibuprofen). In head-to-head comparisons between active interventions, eletriptan was the most effective drug for pain freedom at two hours (odds ratios from 1.46 (1.18 to 1.81) to 3.01 (2.13 to 4.25)), followed by rizatriptan (1.59 (1.18 to 2.17) to 2.44 (1.75 to 3.45)), sumatriptan (1.35 (1.03 to 1.75) to 2.04 (1.49 to 2.86)), and zolmitriptan (1.47 (1.04 to 2.08) to 1.96 (1.39 to 2.86)). For sustained pain freedom, the most efficacious interventions were eletriptan and ibuprofen (odds ratios from 1.41 (1.02 to 1.93) to 4.82 (1.31 to 17.67)). Confidence in accordance with CINeMA ranged from high to very low. Sensitivity analyses on Food and Drug Administration licensed doses only, high versus low doses, risk of bias, and moderate to severe headache at baseline confirmed the main findings for both primary and secondary outcomes. Conclusions Overall, eletriptan, rizatriptan, sumatriptan, and zolmitriptan had the best profiles and they were more efficacious than the recently marketed drugs lasmiditan, rimegepant, and ubrogepant. Although cost effectiveness analyses are warranted and careful consideration should be given to patients with a high risk cardiovascular profile, the most effective triptans should be considered as preferred acute treatment for migraine and included in the WHO List of Essential Medicines to promote global accessibility and uniform standards of care. Systematic review registration Open Science Framework . The full dataset and information for the vitruvian plots are freely available online at GitHub ().

中文翻译：

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药物干预对成人偏头痛发作急性管理的比较效果： 系统评价和网络荟萃分析


目的 比较所有获得许可的药物干预作为口服单药治疗成人偏头痛急性发作的效果。设计 系统评价和网络荟萃分析。数据来源 Cochrane 对照试验中心注册库、Medline、Embase、ClinicalTrials.gov、欧盟临床试验注册库、WHO 国际临床试验注册平台以及监管机构和制药公司的网站，在 2023 年 6 月 24 日之前没有语言限制。方法 筛选、资料提取、编码和偏倚风险评估独立进行，一式两份进行。对主要分析进行随机效应网络荟萃分析。主要结局是给药后 2 小时无痛的参与者比例，以及给药后 2 至 24 小时持续无痛的参与者比例，两者均未使用急救药物。使用网络荟萃分析置信度（confidence in network meta-analysis， CINeMA）在线工具对证据质量进行分级。使用维特鲁威图来总结结果。一个由临床医生和有偏头痛生活经历的人组成的国际小组共同设计了这项研究并解释了研究结果。选择研究的资格标准根据国际头痛疾病分类对诊断为偏头痛的成人（≥18 岁）进行双盲随机试验。结果 纳入了 137 项随机对照试验，包括 89 445 名参与者，他们被分配到 17 种积极干预中的一种或安慰剂组。与安慰剂相比，所有积极干预措施在两小时疼痛缓解方面均显示出更好的疗效（那拉普坦的比值比为 1.73 （95% 置信区间 （CI） 1.27 至 2.34） 至 5.19 （4.25 至 6.33） 对于依来曲普坦），并且大多数还用于持续疼痛缓解至 24 小时（塞来昔布的比值比为 1.71 （1.07 至 2.74） 到布洛芬的 7.58 （2.58 至 22.27）。在积极干预之间的头对头比较中，依来曲坦是 2 小时缓解疼痛最有效的药物（比值比为 1.46（1.18 至 1.81）至 3.01（2.13 至 4.25）），其次是利扎曲坦（1.59（1.18 至 2.17）至 2.44（1.75 至 3.45））、舒马曲坦（1.35（1.03 至 1.75）至 2.04（1.49 至 2.86））和佐米曲坦（1.47（1.04 至 2.08）至 1.96（1.39 至 2.86））。对于持续无痛，最有效的干预措施是依来曲普坦和布洛芬（比值比从 1.41 （1.02 至 1.93） 到 4.82 （1.31 至 17.67））。根据 CINeMA 的置信度范围从高到极低。对仅美国食品药品监督管理局许可剂量、高剂量与低剂量、偏倚风险以及基线时中度至重度头痛的敏感性分析证实了主要和次要结局的主要发现。结论 总体而言，依来曲坦、利扎曲坦、舒马曲坦和佐米曲坦的疗效最好，它们比最近上市的药物 lasmiditan、rimegepant 和 ubrogepant 更有效。尽管有必要进行成本效益分析，并且应仔细考虑心血管高危患者，但应考虑将最有效的曲坦类药物视为偏头痛的首选急性期治疗方法，并将其纳入 WHO 基本药物清单，以促进全球可及性和统一的护理标准。系统评价注册 开放科学框架 .维特鲁威图的完整数据集和信息可在 GitHub （） 上免费在线获取。