Objective:

To assess whether valproate is an effective migraine abortive.

Background:

Over 1 million migraineurs visit the emergency department annually, where they receive various migraine abortives. Sodium valproate is an accepted migraine preventive, but its efficacy as an abortive is less clear.

Design/Methods:

A literature search was conducted on 25 September 2023 in Pubmed, EMBASE and Scopus using the search terms (migraine[ti] OR headache[ti]) AND (valproate[ti] OR valproic[ti] OR divalproex[ti]). Rayyan was utilized for duplicate detection, abstract screening, and study selection. Randomized controlled trials, cohort studies, and case series reporting clinical outcomes of valproate as a migraine abortive were included. Conflicts were resolved by consensus and full text analysis, and quality assessment was performed. Data was analyzed in R version 4.3.1. for a network meta-analysis.

Results:

Excluding 329 duplicates, 207 studies were identified, and 6 RCTs were included. Valproate resulted in significant pain reduction in 5 of 6 RCTs reporting 10-point pain scale change. Network meta-analysis revealed D2-antagonists as most effective, followed by IV dexamethasone (effect size 2.90 less than D2-antagonists, 95% CI [0.03; 5.76]) then IV VPA (3.41, [1.41; 5.42]), then SQ sumatriptan + IV metoclopramide (5.07, [1.45; 8.70]), then IV sumatriptan alone (5.44, [2.04; 8.85]). Side effects were reported in 0-23% of patients receiving VPA, and in 0-69% of patients receiving comparator treatments. No studies reported SAEs.

Conclusions:

Sodium valproate is effective, tolerable, and safe for rapidly reducing migraine pain severity. It may have similar efficacy to all other treatments evaluated, except for D2 antagonists to which it may be inferior. Additional RCTs with common objective scales are needed to assess the efficacy of VPA compared to other agents.