New migraine prevention guideline expands options, clarifies when to use them

Clinical takeaway: Offer preventive treatment to adults with migraine who have ≥4 migraine days per month, ≥4 moderate-to-severe headache days per month, or substantial migraine-related disability. For many patients, CGRP-targeted therapies, atogepant, and established agents such as topiramate, propranolol, onabotulinumtoxinA, and valproate are all evidence-based options, with treatment selection guided by efficacy, tolerability, safety, cost, and patient preferences.

The American Academy of Neurology (AAN) and American Headache Society (AHS) have published a major update to their migraine prevention guideline, reflecting more than a decade of new evidence and expanding the range of recommended preventive therapies. The update emphasizes shared decision-making and recognizes that no single preventive medication is clearly superior for all patients.

The guideline recommends offering preventive treatment to adults with frequent migraine attacks, defined as ≥4 migraine days per month or ≥4 moderate-to-severe headache days per month, as well as to patients whose migraine substantially impairs daily functioning. Clinicians are encouraged to discuss treatment goals, adverse effects, costs, and patient preferences regarding oral versus injectable therapies.

Among patients without major comorbidities, the guideline identifies several agents with high or moderate confidence for efficacy. For episodic migraine, these include the oral CGRP receptor antagonist atogepant, CGRP monoclonal antibodies eptinezumab, erenumab, fremanezumab, and galcanezumab, as well as propranolol, topiramate, and valproate. For chronic migraine, the same agents are recommended along with onabotulinumtoxinA.

Notably, the guideline highlights CGRP-targeted therapies and atogepant as among the most tolerable options, alongside onabotulinumtoxinA for chronic migraine. In contrast, patients concerned about long-term safety or unknown harms may prefer more established therapies with longer real-world experience, such as propranolol or topiramate.

The authors also provide practical advice for special populations. In patients with medication overuse or medication-overuse headache, preventive therapy should still be offered, with preference given to treatments that have supporting evidence in this population, including CGRP monoclonal antibodies, atogepant, onabotulinumtoxinA, and topiramate.

Pregnancy considerations receive substantial attention. The guideline advises avoiding teratogenic agents such as valproate and topiramate whenever possible in people of childbearing potential. If preventive therapy is necessary during pregnancy, nonpharmacologic strategies should be maximized, and nifedipine, propranolol, metoprolol, or onabotulinumtoxinA may be considered after careful risk-benefit discussions.

Additional recommendations address common comorbidities. Amitriptyline is recommended for patients with fibromyalgia, topiramate may be advantageous in patients with obesity because of its tendency to promote weight loss, and enalapril, nifedipine, or telmisartan may offer a single-drug approach for patients with untreated hypertension and migraine.

The guideline also provides practical guidance on monitoring. Allow most medications at least 8 to 12 weeks at a recommended tolerated dose before judging efficacy and allow onabotulinumtoxinA 24 weeks. Clinicians are encouraged to track headache frequency and disability using tools such as migraine diaries, HIT-6, or MIDAS scores.

“There are a variety of effective preventive medications that work in different ways, including newer classes of medications that have been released in the past several years,” said guideline author Dr. Tamara Pringsheim. “For people experiencing frequent migraine attacks or attacks that affect the ability to function normally, this guideline can help clinicians determine which preventive medications may be able to help.”

What’s changed

• First AAN/AHS migraine prevention update since 2012, incorporating evidence for CGRP monoclonal antibodies and gepants.
• Recommends offering preventive therapy to patients with ≥4 migraine days per month, ≥4 moderate-to-severe headache days per month, or substantial disability.
• Identifies atogepant, eptinezumab, erenumab, fremanezumab, galcanezumab, propranolol, topiramate, and valproate as key evidence-supported options for episodic migraine.
• Adds onabotulinumtoxinA as a recommended option for chronic migraine alongside CGRP-targeted therapies and topiramate.
• Highlights CGRP-targeted therapies, atogepant, and onabotulinumtoxinA as among the best-tolerated preventive options.
• Recommends CGRP monoclonal antibodies, atogepant, onabotulinumtoxinA, and topiramate for patients with medication overuse or medication-overuse headache.
• Adds detailed guidance on treatment selection during pregnancy, lactation, older age, obesity, fibromyalgia, hypertension, and medication overuse.

Source: Potrebic S, et al. (2026 Aug 31) Neurology. Pharmacologic Treatment for Migraine Prevention in Adults Practice Guideline Recommendations: Report of the AAN Guidelines Subcommittee and the American Headache Society