New ACP guideline recommends combination therapy for acute episodic migraines

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Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.   
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1. New ACP guideline recommends combination therapy for acute episodic migraines

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-03095

Editorial: https://www.acpjournals.org/doi/10.7326/ANNALS-25-00372

Summary for Patients: https://www.acpjournals.org/doi/10.7326/ANNALS-24-03095-PS

URL goes live when the embargo lifts           

The American College of Physicians (ACP) has developed new recommendations for treatment of acute episodic migraines in nonpregnant adults in outpatient settings. ACP evaluated pharmacologic treatments known to be effective for migraine treatment using the best available comparative effectiveness evidence of benefits and harms, patients’ values and preferences, and economic evidence in order to prioritize the most effective treatments. The new guideline is published in Annals of Internal Medicine.

In its guideline, ACP makes two recommendations:

• ACP recommends that clinicians add a triptan to a nonsteroidal anti-inflammatory drug to treat moderate to severe acute episodic migraine headache in outpatient settings for nonpregnant adults who do not respond adequately to a nonsteroidal anti-inflammatory drug.
• ACP suggests that clinicians add a triptan to acetaminophen to treat moderate to severe acute episodic migraine headache in outpatient settings for nonpregnant adults who do not respond adequately to acetaminophen.

ACP also provides guidance to clinicians to consider counseling nonpregnant adults to begin treatment for acute migraine headache as soon as possible after its onset by utilizing combination therapy: a triptan with an NSAID or a triptan with acetaminophen.

Migraine is characterized by recurrent episodes of usually moderate to severe intensity headache lasting 4 to 72 hours with or without sensory disturbances, generally pulsating and often accompanied by nausea, vomiting, or aversion to light or sound. The condition remains underdiagnosed and undertreated.

ACP recently published a companion guideline, Prevention of Episodic Migraine Headache using Pharmacologic Treatments in Outpatient Settings, which addressed new recommendations for the prevention of episodic migraine in nonpregnant adults. In that guideline, ACP prioritized treatments based on economic and public and patient’s values and preferences evidence because the benefits and harms of evaluated treatments were balanced. However, for migraine treatment, ACP prioritized the combination of a triptan and an NSAID or acetaminophen because benefits outweighed the harms compared with other pharmacologic treatments.

ACP also recently published Incorporating Economic Evidence in Clinical Guidelines, which is a framework for standardizing the approach to identifying, appraising, and considering economic evidence in the development of ACP clinical guidelines, in recognition of accelerating health care costs and the impact on patients. 

Related evidence reviews:

Patients' Values and Preferences Regarding the Pharmacologic Treatment of Acute Episodic Migraine: A Rapid Review  

https://www.acpjournals.org/doi/10.7326/ANNALS-24-02203

Pharmacologic Treatment of Acute Attacks of Episodic Migraine: A Systematic Review and Network Meta-analysis for the American College of Physicians

https://www.acpjournals.org/doi/10.7326/ANNALS-24-02034

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with someone at ACP, please contact Andrew Hachadorian at ahachadorian@acponline.org. 

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2. Available evidence supports continuing buprenorphine during episodes of acute pain for people with opioid use disorder

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-01917

Editorial: https://www.acpjournals.org/doi/10.7326/ANNALS-25-00410

URL goes live when the embargo lifts          

A systematic review analyzed research on the benefits and harms of acute pain interventions among people with opioid use disorder (OUD). The evidence supports the current best practice of continuing buprenorphine during episodes of acute pain for people with OUD, however, the overall evidence for pain outcomes in people with OUD is low. The researchers suggest there is an important evidence gap on the effect of pain interventions on OUD outcomes. The review is published in Annals of Internal Medicine.

Researchers from Yale School of Medicine, Albert Einstein College of Medicine and colleagues analyzed data from 115 studies evaluating acute pain interventions among adults with OUD. All studies were conducted in hospital or emergency department (ED) settings. The researchers aimed to address three questions: 1) Among adults with OUD, including those prescribed medications for OUD (MOUD), what are the benefits and harms of opioid and nonopioid interventions for acute pain?; 2) Among adults with OUD, including those prescribed MOUD, are opioid and nonopioid interventions for acute pain associated with OUD-related outcomes, including withdrawal, return to nonprescribed opioid use (for those in remission), or treatment initiation or retention?; 3) Do the benefits and harms of acute pain interventions vary by use of MOUD before or during the acute pain episode? Not all of the included studies reported the number of participants with OUD or the method of OUD diagnosis. Pain outcomes were assessed in 15 studies of participants taking buprenorphine, two studies of participants taking methadone, two studies of participants prescribed both buprenorphine and methadone, and 16 studies of participants not prescribed a MOUD. Outcomes related to OUD were assessed in only seven studies. No studies assessed pain or OUD outcomes in participants prescribed naltrexone.

Researchers concluded from 10 controlled cohort studies, continuing buprenorphine in patients already prescribed may be associated with lower or similar pain severity when experiencing acute pain episodes. The researchers found very little evidence for acute pain management with methadone, highlighting a significant research gap as over 400,000 people in the U.S. receive methadone to treat OUD. For people with OUD not prescribed MOUD, acute pain interventions studied included oral clonidine, IM haloperidol and midazolam with concurrent IV morphine, and intraoperative IV lidocaine and resulted in improved pain outcomes, but these studies were conducted on mostly men and almost exclusively in Iran. Most studies of interventions have not included OUD outcomes or extended study periods long enough to observe overall trajectories of patients. The researchers recommend future studies of pain interventions among those with OUD include outcomes related to opioid withdrawal and cravings, return to nonprescribed opioid use, treatment retention. The researchers suggest further research to close this evidence gap is urgently needed in light of the ongoing opioid crisis.  

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Michele Buonora, MD, MS, MHS, please email buonora@montefiore.org.

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Also new in this issue:

Racing to Nowhere - Primary Care Productivity Benchmarks and the Red Queen's Race

Mark Earnest, MD, PhD

Ideas and Opinions

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-03544