Meta-Analysis of Oral Triptans

Dear sir In a meta-analysis of oral triptans (1, 2) almotriptan 12.5 mg, rizatriptan 10 mg and eletriptan 80 mg were judged to be better than the standard triptan sumatriptan 100 mg. One of the advantages of almotriptan was its sustained pain free response (25.9%; 95% confidence intervals (CI): 22.9–29.1%) considered to be higher than the response to sumatriptan (20.0%; 95% CI: 18.2–21.3%) (2). In one head-to-head comparative trial with almotriptan 12.5 mg (n = 183) and sumatriptan 100 mg (n = 193), reported in a review (3), almotriptan (24.6%) was, however, not superior to sumatriptan (28.5%) for sustained pain free. In another much larger randomized clinical trial (4), not included in the metaanalysis (1, 2), pain free response at 2 h after sumatriptan 50 mg (24.6%) (n = 591) was superior to that after almotriptan 12.5 mg (17.9%) (n = 582, 95% CI: +2–8%). This study (4) allows to answer whether there is a real, and clinically relevant, difference in sustained pain free response for almotriptan 12.5 mg vs. sumatriptan 50–100 mg. It should be noted that sustained pain free response (no pain after 2 h, no recurrence of headache within 24 h, and no use of escape medication (1, 2)) was not part of the original statistical analyses performed on the results of the studies in the triptan trial programmes. It is a post hoc analysis (1, 2) and one should be cautious in using this efficacy measure when comparing the triptans. Results for sustained pain free response in a meta-analysis (1, 2) should always be confirmed by results from head-to-head comparisons. I invite Almirall Prodesfarma to make available to clinicians, interested in the comparative efficacy of the triptans, the sustained pain free response from the large headto-head comparative trial (4), for a fair judgement of the relative merits of almotriptan.