The use of combination therapies in the acute management of migraine

Abouch Valenty Krymchantowski

Headache Center of Rio, Rio de Janeiro, Brazil; Outpatient Headache Unit of the Instituto de Neurologia, Deolindo Couto, Rio de Janeiro, Brazil

Background and objectives: Migraine is a highly prevalent neurological disorder with multiple peripheral and central mechanisms. Targeting a single mechanism for treating individual attacks as well as for performing the prophylaxis has been shown to be only partially effective. Recently, the role of combining agents for acute migraine treatment has gained attention and the combination of a triptan plus a non-steroidal anti-inflammatory drug (NSAID) has demonstrated better efficacy. This review focuses on the fundamentals of treating migraine attacks with two or more agents, and emphasizes the characteristics of the recently approved fixed combination sumatriptan–naproxen.

Methods: A PubMed search using the terms “migraine”, “treatment”, “acute”, “triptans”, “non-steroidal anti-inflammatory drugs”, “sumatriptan”, “naproxen”, and “combination” was used. In addition, abstracts presented in the major meetings of the American Headache and the International Headache Societies along with the American Academy of Neurology were also evaluated.

Results: Although most of the few studies encountered were not controlled, there is a clear trend for better efficacy in combining triptans with NSAID. Additionally, the results of two recent large and controlled studies using fixed combinations of sumatriptan (50 mg and 85 mg) with 500 mg naproxen sodium confirm the initial observations of the clear superiority of this combination over the use of each agent alone. The differences in the endpoints 24-hour painrelief response as well as pain-free and pain-relief parameters at 2-hour time-point are the most noticeable efficacy measures. Tolerability was not different between studied drugs.

Conclusions: Combining triptans with NSAID and other agents for the acute treatment of migraine suggests better outcome efficacy measures than the use of single agents. The fixed combination of sumatriptan and naproxen sodium offers improved 2-hour and 24-hour benefits over monotherapy with each one these options. Recently issued FDA approval for marketing the combination (sumatriptan 50 mg–naproxen 500 mg) emphasizes the usefulness and safety of this new treatment for migraine attacks.

Keywords: migraine, acute treatment, sumatriptan, naproxen, combination