Pharmacological Management of Acute Migraine: A Systematic Review Comparing NSAIDs, Triptans, Gepants, and Opioids

Abstract

Background. Migraine is a complex neurobiological disorder associated with the activation of the trigeminovascular system. Many new publications about new drugs appear, but not all of them assign the drug to the most appropriate group of patients.
Materials and Methods. We used PubMed to search for studies published between 2016 and 2026. We searched meta-analyses, original clinical trials, and clinical guidelines. Studies were assessed for efficacy and side effects of individual therapeutic substances.

Aim. The aim is to compare pharmacological methods used in the acute treatment of migraine attacks (NSAIDs, triptans, ditans, gepants, and opioids), with a particular emphasis on safety profiles and target patient populations.

Results. Modern NSAID formulations optimize absorption speed and treatment tolerability. Triptans are the gold standard, but their bothersome side effects frequently lead to therapy discontinuation. An effective alternative for patients with cardiovascular contraindications or insufficient response to triptans (TIR) ​​are new drugs – ditans (lasmiditan) and gepants (e.g. ubrogepant). Lasmiditan demonstrates high efficacy, although, unfortunately, it causes central nervous system symptoms (including dizziness). Gepants, which block the CGRP receptor, offer a favorable tolerability profile and consequently result in high patient satisfaction. Furthermore, the review outlines the issue of opioid use in the pediatric population and emergency departments, bringing out its lack of effectiveness and the associated risk of pain chronification.
Conclusions. New drug classes, such as gepants and ditans, are changing migraine management by bypassing the vascular component and enabling better therapy personalization.