Guideline Update

AAN, AHS Issue Updated Adult Migraine Prevention Guideline

Anthony Calabro, MA

Key Highlights

  • Clinicians should offer preventive treatment to patients with ≥4 migraine days per month, ≥4 moderate to severe headache days per month, or substantial migraine-related disability.
  • Treatment selection should reflect efficacy, tolerability, safety, cost, comorbidities, reproductive considerations, and patient preferences.
  • Most preventive medications should be evaluated after at least 8 to 12 weeks at the recommended tolerated dose; onabotulinumtoxinA should be evaluated after 24 weeks.
  • Preventive treatment should be offered to patients with medication overuse or medication-overuse headache.

An updated evidence-based practice guideline published in Headache provides recommendations for pharmacologic migraine prevention in adults, including when to begin treatment, how to select a medication, and how to assess treatment efficacy and adverse effects. The guideline was jointly developed by the American Academy of Neurology (AAN) and the American Headache Society (AHS) and was endorsed by the American Academy of Family Physicians.

A multidisciplinary panel conducted a systematic review of studies published through June 6, 2024, following the process described in the 2017 AAN Clinical Practice Guideline Process Manual. The review evaluated pharmacologic preventive treatments against placebo or active comparators for reducing headache frequency and improving patient-reported quality of life. Structured rationales incorporated evidence from the systematic review, related evidence, principles of care, and inferences from the evidence. Recommendations were classified as Level A (“must”), Level B (“should”), or Level C (“may”).

Study Findings

The guideline recommends offering preventive treatment to adults who experience ≥4 migraine days per month, ≥4 moderate to severe headache days per month, or substantial migraine-related disability. Because no single medication has demonstrated clear superiority for reducing migraine frequency, treatment selection should incorporate efficacy evidence, tolerability, safety, cost, comorbidities, contraindications, method of administration, and patient preferences.

Preventive medications supported by high- or moderate-confidence efficacy evidence include atogepant, eptinezumab, erenumab, fremanezumab, galcanezumab, topiramate, and valproate for episodic and chronic migraine. Propranolol is also included for episodic migraine, whereas onabotulinumtoxinA is included for chronic migraine.

The guideline provides additional recommendations for specific populations. Clinicians should offer topiramate when considering an oral preventive medication for patients with increased body mass index and amitriptyline for patients with comorbid fibromyalgia. Enalapril, nifedipine, or telmisartan may be considered as monotherapy for patients with migraine and untreated hypertension. Preventive medication should also be offered to patients with medication overuse or medication-overuse headache.

People of childbearing potential who require preventive therapy must be informed about potential fetal risks from unplanned exposure, and medications with known teratogenic effects, including divalproex sodium and topiramate, should be avoided if possible. Patients who are pregnant, planning pregnancy, or lactating require counseling about fetal or infant exposure and individualized risk-benefit discussions. Older adults should be assessed for vascular disease, drug interactions, reduced renal or hepatic function, sedation, confusion, hypotension, and fall risk.

For most preventive medications, clinicians should wait at least 8 to 12 weeks at the recommended tolerated dose before assessing efficacy. OnabotulinumtoxinA should be evaluated after 24 weeks at the recommended dose. Assessment should be patient-centered and consider migraine frequency, severity, associated symptoms, quality of life, acute treatment use, and individual goals.

Clinical Implications

According to the guideline authors, shared and informed decision-making should guide the initiation, selection, monitoring, and discontinuation of preventive therapy. Clinicians should counsel patients about common and serious adverse effects, monitor for these effects during routine follow-up, and discuss the potential benefits and risks of tapering an effective preventive medication after 6 months.

Expert Commentary

“These findings provide a clear, evidence-based summary of treatment benefits to help guide informed decisions about migraine prevention,” the researchers concluded in the Plain Language Summary.

Reference
Potrebic S, Tanveer S, Becker WJ, et al. Pharmacologic treatment for migraine prevention in adults: practice guideline recommendations. Headache. 2026;00:1-12. doi:10.1111/head.7019