New Migraine Prevention Guidelines Released

Updated migraine prevention guidance incorporates calcitonin gene-related peptide (CGRP)-targeted therapies and places greater emphasis on individualized treatment selection based on patient priorities.Developed by the American Academy of Neurology (AAN) and American Headache Society, the updated guideline replaces recommendations issued in 2012 and covers pharmacologic prevention of both episodic and chronic migraine in adults.“Since the previous guidelines were published in 2012, there has been a wealth of new treatment available for prevention of migraine, and specifically the migraine-specific CGRP targeted therapy category. The inclusion of these newer treatments is going to be the biggest difference from the older guidelines,” guideline author Rebecca Burch, MD, said during a media briefing.The update brings together evidence on newer and established therapies to help clinicians choose among them based on efficacy, tolerability, long-term safety, and cost, said Burch, associate professor of neurological sciences at the Larner College of Medicine, University of Vermont in Burlington.The guideline was simultaneously published online on August 31 in Neurology and Headache.Preventive Therapy UnderutilizedThe guideline recommends telling all patients with migraine that effective preventive treatments are available. Preventive therapy should be offered to those with at least 4 migraine days per month, at least 4 moderate-to-severe headache days per month, or substantial migraine-related disability.Burch noted that preventive medications reduce headache days and migraine-associated disability and may help prevent progression from episodic to chronic migraine. Despite those benefits, preventive therapy remains underutilized.“One of the goals with this guideline was to be clear about who is eligible for prevention, and it really is more people than are receiving preventive treatment right now,” she said.The guideline emphasizes that no single preventive medication has been shown to be clearly superior in efficacy and that treatment choice should be a collaborative decision based on the patient’s medical and psychiatric history, contraindications, tolerance for adverse effects, and preference for oral or injectable therapy.For patients without major comorbidities or contraindications who prioritize efficacy, the guideline recommends agents with high or moderate confidence in the evidence. For episodic migraine, recommended options include atogepant; the CGRP monoclonal antibodies eptinezumab, erenumab, fremanezumab, and galcanezumab; and propranolol, topiramate, and valproate. For chronic migraine, the list is similar, with onabotulinumtoxinA included instead of propranolol.For patients particularly concerned about tolerability, clinicians should offer atogepant or one of the CGRP monoclonal antibodies, as well as onabotulinumtoxinA for chronic migraine.When potential long-term or unknown harms are a concern, the guideline recommends medications with a long history of clinical use, including propranolol, topiramate, and onabotulinumtoxinA, depending on migraine type. Cost and insurance coverage should also factor into treatment selection.The guideline also offers more specific guidance on how long to continue a treatment trial before assessing effectiveness. For most preventive medications, clinicians should wait 8-12 weeks at the recommended tolerated dose before evaluating efficacy.For onabotulinumtoxinA, the recommended trial is longer: clinicians should wait 24 weeks at the recommended dose before assessing efficacy. If response remains suboptimal after 12-24 weeks and alternatives are available, clinicians and patients should discuss switching treatments.Headache in Pregnancy a Key FocusBurch said she did not expect many of the recommendations to surprise headache specialists, although the section on pregnancy could draw particular attention because it addresses an area “the field of neurology and headache medicine has been very actively discussing recently.”For patients of childbearing potential who require preventive therapy, the guideline recommends counseling regarding potential fetal risks in the event of an unplanned pregnancy.Medications with known teratogenic effects, including divalproex sodium and topiramate, should be avoided when possible.For patients who are pregnant or planning pregnancy, the guideline recommends maximizing nonpharmacologic approaches, including behavioral interventions, acupuncture, exercise, and trigger management.If preventive medication is needed during pregnancy, clinicians may offer nifedipine, a calcium channel blocker used to treat hypertension. The American College of Obstetricians and Gynecologists considers it a first-line option for headache prevention in pregnancy.If that’s not effective or not an option, metoprolol or propranolol may be considered after weighing fetal risks against potential benefits.For chronic migraine, onabotulinumtoxinA may also be considered, although pregnancy outcome data are extremely limited.Beyond pregnancy, the guideline also addresses how comorbid conditions can inform preventive treatment selection. Clinicians are encouraged to consider whether a single drug can reasonably treat both migraine and a coexisting condition.For example, amitriptyline should be offered to patients with migraine and fibromyalgia, while topiramate should be offered when an oral preventive is being considered in patients with increased BMI.The guideline also recommends preventive treatment for patients with medication overuse or medication-overuse headache, preferentially using agents with evidence in this population, including CGRP monoclonal antibodies, atogepant, onabotulinumtoxinA, and topiramate.Burch said the broader aim is to make the increasingly complex preventive treatment landscape easier for clinicians and patients to navigate.“My hope is that this guideline helps clinicians feel more comfortable prescribing preventive treatments for people with migraine.”Funding for the guideline update was provided by the AAN. Disclosures for guideline authors are available with the original publications.