title: A Comparative Effectiveness Meta-Analysis of Drugs for the Prophylaxis of Migraine Headache.
abstract: OBJECTIVE
  To compare the effectiveness and side effects of migraine prophylactic medications.
  
  
  METHODS
  We performed a network meta-analysis. Data were extracted independently in duplicate and quality was assessed using both the JADAD and Cochrane Risk of Bias instruments. Data were pooled and network meta-analysis performed using random effects models.
  
  
  METHODS
  PUBMED, EMBASE, Cochrane Trial Registry, bibliography of retrieved articles through 18 May 2014.
  
  
  METHODS
  We included randomized controlled trials of adults with migraine headaches of at least 4 weeks in duration.
  
  
  RESULTS
  Placebo controlled trials included alpha blockers (n = 9), angiotensin converting enzyme inhibitors (n = 3), angiotensin receptor blockers (n = 3), anticonvulsants (n = 32), beta-blockers (n = 39), calcium channel blockers (n = 12), flunarizine (n = 7), serotonin reuptake inhibitors (n = 6), serotonin norepinephrine reuptake inhibitors (n = 1) serotonin agonists (n = 9) and tricyclic antidepressants (n = 11). In addition there were 53 trials comparing different drugs. Drugs with at least 3 trials that were more effective than placebo for episodic migraines included amitriptyline (SMD: -1.2, 95% CI: -1.7 to -0.82), -flunarizine (-1.1 headaches/month (ha/month), 95% CI: -1.6 to -0.67), fluoxetine (SMD: -0.57, 95% CI: -0.97 to -0.17), metoprolol (-0.94 ha/month, 95% CI: -1.4 to -0.46), pizotifen (-0.43 ha/month, 95% CI: -0.6 to -0.21), propranolol (-1.3 ha/month, 95% CI: -2.0 to -0.62), topiramate (-1.1 ha/month, 95% CI: -1.9 to -0.73) and valproate (-1.5 ha/month, 95% CI: -2.1 to -0.8). Several effective drugs with less than 3 trials included: 3 ace inhibitors (enalapril, lisinopril, captopril), two angiotensin receptor blockers (candesartan, telmisartan), two anticonvulsants (lamotrigine, levetiracetam), and several beta-blockers (atenolol, bisoprolol, timolol). Network meta-analysis found amitriptyline to be better than several other medications including candesartan, fluoxetine, propranolol, topiramate and valproate and no different than atenolol, flunarizine, clomipramine or metoprolol.
  
  
  CONCLUSIONS
  Several drugs good evidence supporting efficacy. There is weak evidence supporting amitriptyline's superiority over some drugs. Selection of prophylactic medication should be tailored according to patient preferences, characteristics and side effect profiles.
authors.affiliation: General Internal Medicine, Zablocki VA Medical Center, Milwaukee, Wisconsin, United States of America.
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Jackson
authors.affiliation: Department of Medicine, Western Michigan School of Medicine, Kalamazoo, Michigan, United States of America.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Cogbill
authors.affiliation: Division of Hematology and Oncology, University of Washington, Seattle, Washington, United States of America.
authors.forename: Rafael
authors.initials: R
authors.lastname: Santana-Davila
authors.affiliation: Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America.
authors.forename: Christina
authors.initials: C
authors.lastname: Eldredge
authors.affiliation: Department of Pharmacology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America.
authors.forename: William
authors.initials: W
authors.lastname: Collier
authors.affiliation: School of Health Sciences, Gollis University, Hergaisa, Somaliland.
authors.forename: Andrew
authors.initials: A
authors.lastname: Gradall
authors.affiliation: Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America.
authors.forename: Neha
authors.initials: N
authors.lastname: Sehgal
authors.affiliation: General Internal Medicine, Zablocki VA Medical Center, Milwaukee, Wisconsin, United States of America.
authors.forename: Jessica
authors.initials: J
authors.lastname: Kuester
mesh_terms: D002986:Clinical Trials as Topic; D006801:Humans; D008881:Migraine Disorders / Q000517:prevention & control*; D016896:Treatment Outcome