Preventive drug treatments for adults with chronic migraine: a systematic review with economic modelling

• Published in: Health technology assessment (Winchester, England) England), 2024-10, Vol.28 (63), p.1-329
• Main Authors: Mistry, Hema, Naghdi, Seyran, Brown, Anna, Rees, Sophie, Madan, Jason, Grove, Amy, Khanal, Saval, Duncan, Callum, Matharu, Manjit, Cooklin, Andrew, Aksentyte, Aiva, Davies, Natasha, Underwood, Martin
• Format: Article
• Language: English
• Subjects: Adult; Antibodies, Monoclonal - economics; Antibodies, Monoclonal - therapeutic use; Antibodies, Monoclonal, Humanized - adverse effects; Antibodies, Monoclonal, Humanized - economics; Antibodies, Monoclonal, Humanized - therapeutic use; Botulinum Toxins, Type A - economics; Botulinum Toxins, Type A - therapeutic use; Calcitonin Gene-Related Peptide - antagonists & inhibitors; Calcitonin Gene-Related Peptide Receptor Antagonists - therapeutic use; Chronic Disease; chronic migraine; Cost-Benefit Analysis; economic analysis; Fructose - analogs & derivatives; Fructose - therapeutic use; Humans; Migraine Disorders - drug therapy; Migraine Disorders - prevention & control; Models, Economic; Network Meta-Analysis; prophylactic medications; Quality of Life; Quality-Adjusted Life Years; Randomized Controlled Trials as Topic; systematic review; Technology Assessment, Biomedical; Topiramate - therapeutic use
• ISSN: 2046-4924; 1366-5278; 2046-4924
• DOI: 10.3310/AYWA5297

Chronic migraine is a disabling condition, affecting 2-4% of adults globally. With the introduction of expensive calcitonin gene-related peptide monoclonal antibodies, it is timely to compare the clinical effectiveness and cost-effectiveness of preventive drugs for chronic migraine. To assess the clinical effectiveness and cost-effectiveness of medications used for chronic migraine through systematic reviews and economic modelling. Randomised controlled trials of drug treatments for efficacy with > 100 participants with chronic migraine per arm; for adverse events > 100 participants with episodic or chronic migraine per arm. Previous economic analyses of preventive drugs for chronic migraine. Eight databases. Systematic reviews, network meta-analysis and economic modelling. Monthly headache days, monthly migraine days, headache-related quality of life, cost-effectiveness. We found 51 individual articles, reporting 11 randomised controlled trials, testing 6 drugs (topiramate, Botox, eptinezumab, erenumab, fremanezumab, galcanezumab), versus placebo, on 7352 adults with chronic migraine. Calcitonin gene-related peptide monoclonal antibodies, Botox and topiramate reduced headache/migraine days by 2.0-2.5, just under two, or by less than 1.5 days per month, respectively. In the network meta-analysis, eptinezumab 300 mg and fremanezumab monthly ranked in first place in both monthly headache day and monthly migraine day analyses. The calcitonin gene-related peptide monoclonal antibodies were consistently the best choices for headache/migraine days and headache-related quality of life. Topiramate was very unlikely to be the best choice for headache/migraine days and headache-related quality of life when compared to calcitonin gene-related peptide monoclonal antibodies or Botox. We found no trials of the commonly used drugs, such as propranolol or amitriptyline, to include in the analysis. The adverse events review included 40 randomised controlled trials with 25,891 participants; 3 additional drugs, amitriptyline, atogepant and rimegepant, were included. There were very few serious adverse events - none of which were linked to the use of these medications. Adverse events were common. Most people using some calcitonin gene-related peptide monoclonal antibodies reported injection site issues; and people using topiramate or amitriptyline had nervous system or gastrointestinal issues. The cost-effectiveness review identified 16 studies evaluating chronic migraine med