Combining different classes of drugs for the acute treatment of migraine

Migraine is a highly prevalent neurological disorder involving multiple mechanisms. Targeting a single mechanism for treating individual attacks has been shown to be only partially effective. Recently, the fundamentals of combining agents for the acute migraine treatment has gained attention and the specific combination of a triptan plus a nonsteroidal anti-inflammatory drug (NSAID) has demonstrated better efficacy than the use of each of these drugs alone. This article reviews the available literature for treating migraine attacks with two or more agents simultaneously. A MEDLINE search using the terms migraine, acute treatment, triptans, NSAIDs, and combination was used. In addition, abstracts presented in the major meetings carried out during the last 5 years by the American Headache and the International Headache Societies along with the American Academy of Neurology were also evaluated. Although most of the studies encountered were not controlled, there is a clear trend for the better efficacy in combining triptans with NSAID. Additionally, the results of recent large and controlled studies using the fixed combinations of sumatriptan with naproxen sodium confirm the initial observations of the clear superiority of this combination over the isolated use of each agent. The differences in the endpoints of pain free and pain relief at 2-h time-points as well as 24-h pain-relief response are the clearest efficacy advantages. Tolerability was not different between the two studied drugs. Combining triptans with NSAIDs 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-h and 24-h benefits over monotherapy with each one these options.