Updated Guideline Refines Approach to Migraine Prevention in Adults

The American Academy of Neurology (AAN) and American Headache Society (AHS) issued an updated practice guideline for the pharmacologic prevention of migraine in adults, giving clinicians and pharmacists a structured framework for deciding when to start preventive therapy and which medication to choose.¹

Published in Neurology, the guideline was developed by a multidisciplinary panel following the process outlined in the 2017 AAN Clinical Practice Guideline Process Manual and is based on a systematic review of studies published through June 6, 2024. The recommendations arrive as pharmacists describe a wide gap between the number of patients living with migraine and the specialists available to treat them.¹

New Thresholds for Starting and Choosing Preventive Therapy

The guideline defines chronic migraine as headache occurring 15 or more days per month for more than 3 months, with migraine features present on at least 8 days per month. It recommends that clinicians inform all patients that effective preventive treatments exist and offer preventive therapy to those with 4 or more migraine days per month, 4 or more moderate-to-severe headache days per month, or substantial migraine-related disability.¹

A cross-sectional study cited in the guideline found that 80% of patients with 5 or more migraine attacks per month expressed interest in pharmacologic prevention compared with 20% of patients with fewer than 2 attacks per month.¹

Once a patient and clinician decide to start preventive therapy, the guideline calls for shared decision-making that accounts for medical and psychiatric history, current medications, contraindications, and patient preferences around adverse effects and treatment modality—oral versus injectable—while weighing 4 properties: strength of evidence for efficacy, tolerability, safety, and cost.¹

For efficacy-focused choices, the guideline gives high or moderate confidence in episodic migraine to atogepant, eptinezumab, erenumab, fremanezumab, galcanezumab, propranolol, topiramate, and valproate. For chronic migraine, that same confidence applies to the group with onabotulinumtoxinA in place of propranolol.¹

Patients most concerned about tolerability can be offered atogepant, eptinezumab, erenumab, fremanezumab, and galcanezumab for episodic migraine, with onabotulinumtoxinA added for chronic migraine. Those wary of long-term or unknown harms can be offered propranolol and topiramate for episodic disease or onabotulinumtoxinA and topiramate for chronic migraine, and cost is weighed against each patient's formulary and insurance coverage.¹

Added Counseling Points for Pregnancy, Lactation, and High-Risk Patients

For patients of childbearing potential, the guideline calls for counseling on the risk that agents with known teratogenic effects—such as divalproex sodium and topiramate—pose in an unplanned pregnancy and says those agents should be avoided if possible. If pharmacologic prevention is necessary during pregnancy, clinicians may offer nifedipine, and if nifedipine is not an option or is ineffective, metoprolol or propranolol may be offered while balancing risks such as cardiovascular abnormalities, cleft lip or palate, neural tube defects, and fetal growth restriction against the benefits.¹

During lactation, the guideline says clinicians must counsel patients that migraine preventives pass into breast milk in varying amounts and can affect breastfed infants, drawing on evidence-based resources such as LactMed.¹

Additional counseling points include informing female patients that valproic acid can increase the risk of polycystic ovary syndrome and that topiramate doses above 200 mg per day can make hormonal contraception less effective. For older adult male patients, the guideline calls for evaluating the risk of urinary retention and avoiding anticholinergic drugs such as amitriptyline or discussing that risk with the patient.¹

The guideline also recommends preventive therapy for patients with medication overuse—regular use of acute migraine drugs more than 9 days per month for prescription pain-relieving medication or more than 14 days per month for nonspecific pain medications—prioritizing options such as calcitonin gene-related peptide (CGRP) monoclonal antibodies, atogepant, onabotulinumtoxinA, and topiramate.¹

CGRP Therapies Reshape Care Amid a Workforce Gap

Erenumab received FDA approval in 2018 as the first medication designed strictly for migraine prevention, and CGRP-targeted options have multiplied since. Amaal J. Starling, MD, FAAN, FAHS, associate professor of neurology at Mayo Clinic College of Medicine and Science, said CGRP is central to that shift.²

"CGRP is a neuropeptide that plays a significant role in migraine. We have [data from] basic science studies that show that levels of this peptide are elevated during migraine attacks," Starling said.² She noted that individuals with more severe forms of migraine tend to have chronically elevated CGRP levels and that animal models have shown blocking the CGRP pathway can reduce migraine pain.

"There are 2 paradigms for treatment in migraine," Starling said.³ "One is treatment of the individual attack, that's acute treatment, and then there's also treatment that is preventive, which is aimed to reduce the frequency of attacks as well as manage the underlying disease process."

That breadth of options is colliding with a shortage of specialists. An estimated 50 million patients in the United States experience migraine, and fewer than 900 certified headache specialists are available nationally, leaving many patients waiting months between visits.⁴

"After many, many months of wait, we are unable to do frequent follow-ups. The vast majority of my patients I can usually see once every 6 months, and that is even challenging sometimes," Starling said, adding that ideally she would like to see patients at least every 3 months.⁴

Addressing that gap, Starling said, will require expanding who manages migraine care beyond neurology.

"What we need is workforce expansion in migraine. Right now, we've got headache specialists—very few of us—we've got general neurologists; we've got primary care providers; and we have been working with these 3 groups over the last several decades to try to improve the management of migraine. But we have not been able to significantly move the needle at a population level," she said.⁵

With screening, medication management, and patient counseling cited as pharmacist-accessible touchpoints in migraine care, the updated AAN and AHS guideline gives community pharmacists a clearer evidence base to support that expanded role.¹

REFERENCES

1. Potrebic S, Tanveer S, Becker WJ, et al. Pharmacologic treatment for migraine prevention in adults practice guideline recommendations: report of the AAN Guidelines Subcommittee and the American Headache Society. Neurology. 2026;107(7):e214881. doi:10.1212/WNL.0000000000214881

2. Nowosielski B. The emergence of CGRP-targeted therapies is transforming migraine care. Drug Topics. October 20, 2025. Accessed September 1, 2026. https://www.drugtopics.com/view/the-emergence-of-cgrp-targeted-therapies-is-transforming-migraine-care-ncpa-2025

3. Nowosielski B. The variety of migraine treatment options opens the door for pharmacy services. Drug Topics. October 18, 2025. Accessed September 1, 2026. https://www.drugtopics.com/view/the-variety-of-migraine-treatment-options-opens-the-door-for-pharmacy-services-ncpa-2025

4. Nowosielski B. Workforce, access challenges impede patients' ability to manage migraines. Drug Topics. October 20, 2025. Accessed September 1, 2026. https://www.drugtopics.com/view/workforce-access-challenges-impede-patients-ability-to-manage-migraines-ncpa-2025

5. Nowosielski B. How community pharmacists are proactively managing patients' migraines. Drug Topics. October 18, 2025. Accessed September 1, 2026. https://www.drugtopics.com/view/how-community-pharmacists-are-proactively-managing-patients-migraines-ncpa-2025