Migraine is a common neurological condition that may cause severe, throbbing head pain, often on one side of the head, along with other physical symptoms.
During an episode, people may experience nausea, sensitivity to light and sound, dizziness, visual disturbances, or difficulty thinking. Attacks can last from several hours to several days and may substantially interfere with daily life. Estimates suggest they affect roughly 12 to 15% of the American population, accounting for about 40 million people.
The American Academy of Neurology (AAN) and American Headache Society (AHS) have issued a joint practice guideline update with evidence-based recommendations.
The updated guidance, published in Neurology, the medical journal of the AAN, and in Headache, the official journal of the AHS, is an update to the AAN and AHS 2012 guidelines, and is also endorsed by the American Academy of Family Physicians.
The guideline incorporates evidence on newer migraine-prevention medications alongside established treatments, providing clinicians with guidance on choosing therapies based on factors including effectiveness, side effects, cost, and other health conditions.
Importantly, the organizations suggest that the new guidance means millions more people should be on preventive treatment to help manage their migraine.
Read more:New heart attack definition could improve diagnosis for women
A major change reflected in the updated recommendations is the inclusion of newer preventive therapies that were not available when the previous guideline was published. Preventive medications differ from treatments used during a migraine episode. Rather than being taken only when symptoms occur, preventive therapies are used to reduce the frequency or severity of future episodes.
Since the previous AAN/AHS guideline was published in 2012, the number of available preventive treatments has increased substantially, largely driven by the development and approval of therapies specifically targeting the calcitonin gene-related peptide (CGRP) pathway.
“The new guideline incorporates a wealth of migraine-specific preventive therapies that have strong evidence for use in everyday practice,” explained Matthew Robbins, MD, FAAN, FAHS, President of the American Headache Society and Professor of Neurology at Weill Cornell Medicine.
“The guideline stratifies recommendations by episodic and chronic migraine, the presence of acute medication overuse, special populations such as pregnant [people], and comorbidities,” he explained to Medical News Today.
The new guideline, therefore, aims to help clinicians navigate a broader range of options.
Read more:King Charles III clarifies status of Prince Harry and his wife, Meghan, after their return to the UK
The updated guideline recommends that clinicians consider preventive treatment when adults have:
The recommendations apply to both episodic migraine and chronic migraine.
The guideline defines chronic migraine as headaches occurring on at least 15 days per month for more than 3 months, with migraine features on at least 8 of those days. People with fewer headache days may have episodic migraine.
This threshold does not mean that everyone meeting the criteria should receive the same medication. Instead, the guideline emphasizes considering how much migraine affects an individual’s quality of life and discussing the available options with the individual.
The guideline emphasizes that there is no single preventive medication that is best for everyone. If one treatment is ineffective or poorly tolerated, another type of medication may still work.
Read more:Lindsay Clancy’s case is a rorschach test | Moira Donegan | The Guardian
Rather than recommending a one-size-fits-all approach, the new guideline encourages clinicians and patients to weigh several factors when selecting a preventive treatment.
These include:
Preventive medicines may be available as oral treatments taken daily or every other day, while some injectable options are administered monthly or every 3 months.
This approach may be particularly important because a medication’s benefits can vary by individual. For example, a treatment that is useful for someone with another health condition may be preferable to taking two separate medications.
The guideline also recommends that clinicians reassess patients after starting a new medication, according to the specified timeframes. This allows treatment to be adjusted if it is not sufficiently reducing migraine frequency or is causing problematic side effects.
This highlights the importance of tracking migraine frequency and symptoms after beginning preventive treatment. Keeping a headache diary can give clinicians useful information when determining whether a treatment is helping.
“First of all, once per week is a very patient-centered, easy-to-encapsulate recommendation that can be applied by every clinician and patient who seeks care,” Robbins noted. “Second, this recommendation comes from years of expert opinions and research showing this is an inflection point for migraine-related disability and the beginning of the risk migraine-related chronic migraine if untreated.”
“Third, this recommendation is consistent with indications for entry into all modern-day clinical trials in migraine preventive therapy,” he added.
“It is clear that newer migraine-specific treatments should be first-line preventive therapies, as stated in the most recent American Headache Society position statement published in 2024. These treatments dominate the highest levels of recommendation in the new AAN-AHS guidelines as well.”
— Matthew Robbins, MD, FAAN, FAHS
For someone experiencing frequent or disabling migraine, the updated recommendations suggest that preventive treatment may be worth discussing even if they have not previously considered it.
A clinician can help determine whether preventive therapy is appropriate and, if so, which option best fits the individual’s migraine pattern, other health conditions, preferences, and ability to tolerate potential side effects.
“The AAN-AHS guideline importantly invokes a shared decision making approach. In general, patients should receive the treatment that is the most safe and effective for them. Certainly, cost and access are issues, but are improving over time with newer migraine treatments,” Robbins said.
“[M]igraine is woefully undertreated and millions of people in the U.S. who deserve better care to improve their quality of life and prognosis do not receive it.”
— Matthew Robbins, MD, FAAN, FAHS
The updated guideline does not mean that every person with migraine will require medication. Rather, it provides clinicians with a broader evidence base for deciding when prevention is appropriate and which of the increasingly numerous treatment options may be most suitable.
Anyone considering starting, stopping, or changing a migraine medication should discuss the decision with a healthcare professional.
