The wide heterogeneity in the use of first line treatment for migraine across headache centres globally shows the need for better evidence to inform guidance, researchers say.

A study of 600 patients from seven countries including Australia found the most commonly used acute drugs were triptans (70.3%) especially sumatriptan, followed by NSAIDs (63.3%).

Triptans were more frequently used in Poland and Russia but in general by at least half of patients in all countries.

The use of NSAIDs predominates in countries like Poland and Italy although their use is not as frequent in countries like Australia.

Paracetamol was commonly used in Australia (50.0%) and Poland (64.4%) but its overall use was only 18.7%.

The study, published in the Journal of Headache and Pain, said the differences in usage were expected given there were few comparative studies and no consensus on the drug of first choice.

“In fact, the European guidelines to dictate the new monoclonal treatments against CGRP indicate that at least two oral treatments must be prescribed (and BTX-A in the case of chronic migraine), however, it is not specified which should be the two first options,” said the authors, including Melbourne neurologist Dr Catherine Stark.

Similarly, there was no single first-line drug of choice as preventive treatment.

The most commonly used drugs were antidepressants such as amitriptyline (69.3 %), antiepileptic drugs particularly topiramate (54.7 %) and beta-blockers (49.7 %) – again with significant differences between countries, and in subgroups according to comorbidities.

For example, topiramate was the most widely used neuromodulator in some countries – in about three quarters of Australian and Polish patients and two-thirds of Spanish patients – but much less commonly used in Russia.

“This investigation shows the need for a larger multicentre study to verify these results and to continue with comparative clinical trials between the first line treatments, in order to create global international algorithms that guarantee the best therapeutic option for our patients,” they concluded.