Fourteen double-blind RCTs were included in the review (n=4,112, range 14 to 888), including seven parallel group RCTs and seven cross-over design RCTs. The quality of the included trials was high, with six studies scoring 5 out of a possible 5 on the Jadad scale and six scoring 4 out of 5.
Second-line therapy in an emergency department setting
Intravenous prochlorperazine was more effective than intravenous ketorolac in relieving pain at one hour (one RCT). There were no significant differences in recurrence rates or adverse effects between the two treatments.
First-line therapy in an outpatient neurology clinic setting
Oral ibuprofen (three RCTs) and oral acetaminophen (paracetamol) (one RCT) were more effective than placebo in relieving pain at two hours. There were no significant differences in adverse effects between ibuprofen, acetaminophen and placebo (where reported). Oral sumatriptan (one RCT) was no more effective than placebo. The effectiveness of intranasal sumatriptan (four RCTs), oral rizatriptan (three RCTs), oral zolmitriptan (two RCTs) and oral dihydroergotamine (one RCT) were unclear. Intranasal sumatriptan was associated with more taste disturbance than placebo in three of the four RCTs. There were more adverse effects with zolmitriptan than placebo in both RCTs. One of three RCTs reported more adverse effects with rizatriptan than placebo.