Updated migraine prevention clinical guidelines

The American Academy of Neurology (AAN) and the American Headache Society (AHS) have released updated clinical practice guidelines for migraine prevention in adults, marking the first major update to these recommendations since 2012.

The guidelines incorporate recent medical advancements, specifically focusing on medications that target the calcitonin gene-related peptide (CGRP) pathway. Based on a systematic review of 217 randomized controlled studies, the recommendations evaluate both modern CGRP inhibitors and traditional preventive methods.

For episodic migraine, galcanezumab and erenumab are noted to have the highest level of evidence for reducing headache frequency. Other treatments with moderate evidence include atogepant, eptinezumab, fremanezumab, propranolol, topiramate, and valproate. For chronic migraine—defined as headaches occurring more than 15 days per month—fremanezumab, galcanezumab, and onabotulinumtoxinA are recommended.

Clinicians are advised to offer preventive treatment to patients experiencing four or more migraine days per month, four or more moderate to severe headache days per month, or those whose symptoms significantly impair daily functioning. Experts emphasize that therapy should be individualized, noting that while CGRP therapies represent a significant advancement, older medications remain important alternatives.

Recent updates further clarify that the threshold for starting preventive therapy has been lowered; it is now recommended for patients experiencing four monthly migraine days, a reduction from the previous threshold of eight days. While CGRP inhibitors have established themselves as first-line options, researchers note they can be costly and may carry side effects. Additionally, emerging research into physical interventions suggests that cervical strengthening and stabilization exercises may potentially reduce migraine-related impairments, though evidence for a definitive preventive benefit remains limited.