CGRP-antibodies, topiramate and botulinum toxin type A in episodic and chronic migraine: A systematic review and meta-analysis

Abstract

Background The approval of monoclonal antibodies for prevention of migraine has revolutionized treatment for patients. Oral preventatives are still considered first line treatments as head-to-head trials comparing them with antibodies are lacking. Methods The main purpose of this study was to provide a comparative overview of the efficacy of three commonly prescribed migraine preventative medication classes. For this systematic review and meta-analysis, we searched the databases CENTRAL, EMBASE, and MEDLINE until 20 March 2020. We included RCTs reporting the 50% response rates for topiramate, Botulinum Toxin Type A and monoclonal antibodies against CGRP(r). Studies were excluded if response rates were not reported, treatment allocation was unclear, or if study quality was insufficient. Primary outcome measure were the 50% response rates. The pooled odds ratios with 95% confidence intervals were calculated with the random effects model. The study was registered at PROSPERO (CRD42020222880). Findings We identified 6552 reports. Thirty-two were eligible for our review. Studies assessing monoclonal antibodies included 13,302 patients and yielded pooled odds ratios for the 50% response rate of 2.30 (CI: 2.11–2.50). Topiramate had an overall effect estimate of 2.70 (CI: 1.97–3.69) with 1989 included patients and Botulinum Toxin Type A achieved 1.28 (CI: 0.98–1. 67) with 2472 patients included. Interpretation Topiramate, botulinum toxin type A and monoclonal antibodies showed higher odds ratios in achieving a 50% response rate compared to placebo. Topiramate numerically demonstrated the greatest effect size but also the highest drop-out rate.

Long-term prophylactic efficacy of transcranial direct current stimulation in chronic migraine. A randomised, patient-assessor blinded, sham-controlled trial

“…Thus, the efficacy of a-tDCS of the left motor cortex seems to be comparable to topiramate used as first-line prophylactic treatment in CM. The efficacy of a-tDCS observed in the present study is also comparable to that recently reported in studies J o u r n a l P r e -p r o o f 12 considering the impact of botulinum toxin type A (BTA) or monoclonal antibodies against CGRP (mAbs) on the number of headache days as primary endpoint, reporting an effect size and responder rate of 50% [62,[66][67][68][69]. Thus, the efficacy of a-tDCS of the left motor cortex seems to be at least similar to all medications currently used as prophylactic treatment for CM and also for resistant CM, an observation that must to be confirmed by larger studies.…”

“…The first-line prophylactic treatments of CM are based on medications [58][59][60][61][62]. The anticonvulsant topiramate has been recently recommended as the first-line prophylactic treatment for CM in French guidelines [59], because of the highest level of evidence of efficacy, notably based on a large, multicenter, controlled clinical trial [63].…”

Long‐term adherence, safety, and efficacy of repeated onabotulinumtoxinA over five years in chronic migraine prophylaxis

“…Efficacy, expressed as the 50% response rate (reduction in monthly headache days) compared with placebo, is comparable between anti-CGRPs and BoNTA, while there are no major safety issues with both interventions. 44 Based on lower dropout rates, tolerability seems to be better with anti-CGRPs, 45 although one can argue that the application of BoNTA by a well-trained injector every three months might facilitate better compliance with BoNTA, compared with anti-CGRPs, which have to be self-injected by the patient typically every month, thus potentially being painful at the injection site as a result of their fast rate dispersion into the subcutaneous tissue. 46 In addition, there is evidence to support the beneficial effect of BoNTA injections at different sites, not just the forehead, in reducing the frequency and severity of comorbid psychiatric disorders, including depression and anxiety.…”

New Approaches to Shifting the Migraine Treatment Paradigm

“…One reported both individual mAb reports vs. multiple onabotulinumtoxinA trials but also combined the outcomes of the mAb trials vs. the onabotulinumtoxinA trials ( 61 ). One other examined the three subcutaneous mAbs vs. topiramate and onabotulinumtoxinA in episodic and chronic migraine in a number needed to treat for a 50% responder rate (NNT50%) and likelihood to help or harm 50% rate (LHH50%) ( 62 ).…”