Professional medical organizations released updated guidelines Monday for migraine prevention, marking the first significant revision since 2012. The American Headache Society and American Academy of Neurology developed the recommendations to reflect the expanded treatment landscape that has emerged over the past 14 years.
The guidelines recommend preventive treatment for individuals experiencing at least four migraine or severe headache days per month, or for those whose migraines substantially impact work or daily functioning. An estimated 15% of Americans experience migraines, with women affected at higher rates. The recommendations encompass both episodic migraines and chronic migraine, which is defined as headache occurring 15 or more days per month for over three months, with at least eight days meeting migraine criteria.
Among the major updates are several newer medications targeting the calcitonin-gene related peptide pathway, including atogepant, eptinezumab, erenumab, fremanezumab, and galcanezumab, which received high marks for efficacy and tolerability. The guidelines also address established treatments such as Botox for chronic migraine, propranolol for episodic migraines, and topiramate. Clinicians are advised to evaluate treatment effectiveness after eight to 12 weeks.
The guidelines provide tiered recommendations accounting for factors such as body mass index, fibromyalgia, hypertension status, and pregnancy. However, some clinicians and experts have raised concerns about inconsistencies within the recommendations. Certain treatment suggestions conflict with guidance from other medical organizations, particularly regarding medication use in pregnant patients. Additionally, some commonly used and affordable treatments received lower ratings despite evidence of effectiveness, raising questions about implementation in clinical practice.
The update process began in January 2018 and involved 19 headache specialists and researchers from across North America. Approximately one-third of the panel had relevant financial interests and were excluded from rating evidence, though they participated in final voting on recommendations. Experts note that access to these treatments will ultimately depend on patients’ ability to seek and afford care, as insurance prior authorization remains a significant barrier to treatment initiation.
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