Network meta-analysis of 24 trials (8,789 patients) ranks botulinum toxin A as the most effective chronic migraine prevention, with CGRP monoclonal antibodies as the safest and a close second in efficacy.
CGRP antibodies: safest classEptinezumab had the best safety profile among all chronic migraine prevention drugs, with CGRP mAbs ranking second overall behind botulinum toxin A
What the researchers found
Botulinum toxin A: best efficacy for monthly migraine day reduction (MD 3.88 fewer days). Eptinezumab (CGRP antibody): safest profile (RR 1.09 for adverse events). CGRP mAbs ranked second overall behind botulinum toxin A for combined efficacy and safety.
Why it matters
Chronic migraine patients and their doctors need evidence-based guidance for choosing prevention drugs. This comprehensive ranking places CGRP antibodies — the newest drug class — in context with established options, confirming their value especially for patients who prioritize safety.
The numbers in context
Systematic search through August 1, 2023, identifying eligible RCTs across multiple chronic migraine prevention drug classes.
How the study worked
Network meta-analysis of 24 RCTs (8,789 patients) from 4 databases through August 2023. Compared chronic migraine prevention drugs using monthly migraine days, 50% responder rate, MIDAS scores, and adverse events. Ranked interventions using SUCRA.
Who was studied
Pooled RCT data of chronic migraine patients across multiple prevention drug classes
What this study cannot tell us
Network meta-analysis relies on indirect comparisons between drugs that were rarely tested head-to-head. Different trials used different populations, definitions, and endpoints. Some drugs had more evidence than others. Topiramate's extremely wide confidence interval (3.18-787.30) indicates imprecise estimation.
How to read the evidence
Strong evidence: comprehensive network meta-analysis of 24 RCTs (8,789 patients) published in the Journal of Neurology, though indirect comparisons have inherent limitations.
When this study was published
Published in 2024 with search through August 2023. Includes the latest CGRP antibody trial data.
The bigger picture
The chronic migraine treatment landscape has been transformed by CGRP-targeting peptide drugs. This meta-analysis confirms their place among the top prevention options, particularly for their excellent safety profiles. The finding that no drug significantly improved disability scores highlights a gap in current treatments — migraine days decrease but overall quality of life impact may persist.
Questions still open
- Would direct head-to-head trials confirm the ranking of botulinum toxin A over CGRP antibodies?
- Why did no prevention drug significantly improve MIDAS disability scores despite reducing migraine days?
- Should treatment guidelines be updated to reflect this ranking?
Common questions
Which chronic migraine prevention drug is best?
Are CGRP antibodies better than Botox for migraine?
Read the original research
Effectiveness and safety of pharmacological prophylaxis for chronic migraine: a systematic review and network meta-analysis.
Journal of neurology, 271(9), 5762-5777
Citation
Zhao, Chengqi; Li, Changxin; Yu, Xueping; Dai, Xiaohong; Zou, Wei. (2024). Effectiveness and safety of pharmacological prophylaxis for chronic migraine: a systematic review and network meta-analysis.. Journal of neurology, 271(9), 5762-5777. https://doi.org/10.1007/s00415-024-12512-z