American Academy of Neurology, American Headache Society Issue Updated Guideline on Migraine Prevention

The American Academy of Neurology (AAN) and American Headache Society (AHS) have issued an updated practice guideline on pharmacologic migraine prevention in adults, replacing recommendations last updated in 2012.^1,2 Developed by a multidisciplinary panel based on a systematic review of evidence through June 2024,³ the guideline provides graded recommendations on when to start preventive therapy, how to select among available medications, and how to manage treatment in specific patient populations.

“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,” Tamara Pringsheim, MD, MSc, professor in the Department of Clinical Neurosciences, Psychiatry, Pediatrics and Community Health Sciences at the University of Calgary, and a fellow of the AAN, said in a statement.² “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.”

The guideline defines chronic migraine as headache occurring on 15 or more days per month for more than 3 months, with migraine features present on at least 8 of those days. Migraine occurring less frequently is classified as episodic.

When to start preventive therapy

• Clinicians should inform all patients with migraine that effective preventive treatments exist for frequent attacks (Level B).
• Preventive treatment should be offered to patients with 4 or more migraine days per month, or 4 or more moderate to severe headache days per month, to reduce headache frequency (Level B).
• Preventive treatment should be offered to patients with substantial migraine-related disability, to reduce that disability (Level B).

Shared and informed decision-making

• Clinicians should inform patients of appropriate medication choices, accounting for medical and psychiatric history, current medications, and contraindications (Level B).
• Clinicians should discuss and understand patient preferences regarding potential adverse effects (Level B).
• Clinicians should discuss and understand patient preferences regarding treatment modality, that is, oral versus injectable (Level B).

Choosing a preventive medication

The guideline notes that no single medication has been shown to be clearly superior for efficacy, and recommends comparing options across 4 properties: strength of evidence for efficacy, tolerability, long-term safety, and cost.

For patients for whom efficacy is the priority, clinicians should offer preventives with high or moderate confidence in the evidence (Level B):

• Episodic migraine: atogepant, eptinezumab, erenumab, fremanezumab, galcanezumab, propranolol, topiramate, and valproate.
• Chronic migraine: atogepant, eptinezumab, erenumab, fremanezumab, galcanezumab, onabotulinumtoxinA, topiramate, and valproate.

For patients concerned about tolerability, clinicians should offer preventives with fewer side effects (Level B):

• Episodic migraine: atogepant, eptinezumab, erenumab, fremanezumab, and galcanezumab.
• Chronic migraine: atogepant, eptinezumab, erenumab, fremanezumab, galcanezumab, and onabotulinumtoxinA.

For patients concerned about long-term or unknown harms, clinicians should offer preventives that have been widely used for a long period of time (Level B):

• Episodic migraine: propranolol and topiramate.
• Chronic migraine: onabotulinumtoxinA and topiramate.

Additional episodic migraine options carrying lower confidence in the evidence include amitriptyline, flunarizine, metoprolol, pizotifen, rimegepant, and telmisartan.

Cost and prior response also factor into selection: clinicians should offer less expensive options depending on a patient's formulary and insurance coverage (Level B), and should offer preventives with lower confidence in the evidence for efficacy to patients not responding to higher-confidence choices (Level B).

"The research shows many different types of medications may be effective for preventing migraine attacks and reducing symptoms,” Rebecca C. Burch, MD, associate professor in the Department of Neurological Sciences of the University of Vermont Larner College of Medicine, and a fellow of the AHS, said in a statement.² "It is important for clinicians and patients to know that there are many options."

Pregnancy, lactation, and reproductive planning

• Patients of childbearing potential who require migraine preventive therapy must be made aware of potential risks to the fetus in the event of an unplanned pregnancy, and agents with known teratogenic effects, such as divalproex sodium and topiramate, should be avoided if possible (Level A).
• In patients who are pregnant or planning a pregnancy, nonpharmacologic approaches such as behavioral interventions, acupuncture, exercise, and trigger management must be maximized (Level A).
• If pharmacologic prevention is considered necessary during pregnancy, it must be used only after a thorough discussion of risks and alternatives, with joint decision-making, and clinicians must develop a strategy limiting overall pharmacologic exposure while maintaining the best possible migraine control (Level A).
• If a preventive drug is necessary during pregnancy, clinicians may offer nifedipine (Level C); if nifedipine is not an option or is ineffective, clinicians may offer metoprolol or propranolol, weighing risks including cardiovascular abnormalities, cleft lip or palate, neural tube defects, and fetal growth restriction (Level C).
• For chronic migraine, clinicians may offer onabotulinumtoxinA during pregnancy if necessary, balancing the risks against potential benefits; available outcome data are extremely limited (Level C).
• Clinicians must counsel lactating patients that migraine preventives pass into breast milk in varying, and for newer treatments often poorly characterized, amounts, drawing on evidence-based resources such as LactMed (Level A).

Age and sex-specific considerations

• When prescribing a preventive medication for older adults, clinicians should carefully assess for vascular disease, potential drug interactions, and reduced renal or hepatic function (Level B).
• Clinicians should discuss sedation and confusion risk with medications that have sedative potential, including amitriptyline, valproate, topiramate, and pizotifen, and consider starting at lower-than-usual doses in older adults (Level B).
• Clinicians must discuss the possibility of hypotension or postural hypotension when choosing a preventive drug for an older adult and, if appropriate, avoid drugs that significantly lower blood pressure or start therapy at lower-than-usual doses (Level A).
• Clinicians prescribing valproic acid must notify female patients that it can increase the risk of polycystic ovary syndrome (Level A).
• Clinicians prescribing topiramate must notify female patients of childbearing potential that doses above 200 mg/d can make hormonal contraception less effective (Level A).
• For older adult male patients, clinicians should evaluate the risk of urinary retention and either avoid drugs with anticholinergic effects, such as amitriptyline, or discuss that possibility with the patient (Level B).

Comorbid conditions

• Clinicians should discuss with patients who have a medical or psychiatric comorbidity whether to treat both conditions with a single medication or independently, and if a combined approach is chosen, should monitor closely and be prepared to switch to independent treatment if either condition does not respond (Level B).
• Clinicians may inform patients with migraine and comorbid untreated hypertension that monotherapy options are available to treat both conditions, including enalapril, nifedipine, and telmisartan (Level C).
• Clinicians should offer amitriptyline for migraine prevention in patients with comorbid fibromyalgia (Level B).
• When an oral migraine preventive is being considered in a patient with increased body mass index, clinicians should offer topiramate (Level B).

Medication overuse

• Preventive medication should be offered to patients who meet criteria for medication overuse (Level B) and to those with medication-overuse headache (Level B).
• Preventives with evidence of efficacy in patients with medication overuse or medication-overuse headache, including CGRP monoclonal antibodies, atogepant, onabotulinumtoxinA, and topiramate, should be considered before medications that lack such evidence (Level B).

Monitoring, adjusting, and stopping treatment

• When prescribing a migraine preventive medication, clinicians must evaluate the risk of drug interactions and combined side effects with a patient's acute migraine medications (Level A).
• Clinicians should wait at least 8 to 12 weeks at the recommended tolerated dose of most preventive medications, and 24 weeks for onabotulinumtoxinA injections, before assessing efficacy (Level B).
• If response is suboptimal at 8 weeks, clinicians should optimize the dose to the maximum tolerated or predetermined maximum dose (Level B); if no efficacy is seen after 8 to 12 weeks and other contributing factors are identified, such as inconsistent adherence or frequent trigger exposure, clinicians should engage in shared decision-making to continue an additional observation period (Level B).
• Clinicians should document attack frequency and consistently use a measurement tool, such as a headache diary, HIT-6, or MIDAS, to monitor treatment response (Level B/C), and should base assessment of efficacy on frequency, severity, associated symptoms, quality of life, and use of acute therapy (Level B).
• If side effects are not tolerable, clinicians should consider a dose reduction or offer an alternative treatment (Level B); if response remains suboptimal after 12 to 24 weeks and other options are available, clinicians should engage in shared decision-making to initiate an alternate medication (Level B).
• Clinicians must provide counseling on common and serious or life-threatening adverse effects, based on product monographs and drug information databases, before prescribing, and must monitor for these effects as part of routine follow-up (Level A).
• Clinicians should counsel patients that limited evidence suggests a risk of increased headache days and decreased headache-related quality of life after discontinuing a preventive medication, and should discuss the potential benefits and risks of tapering after 6 months of treatment (Level B).

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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. AAN and AHS issue updated guideline on migraine prevention medications for adults. News release. American Academy of Neurology. August 31, 2026. Accessed September 1, 2026. https://www.aan.com/PressRoom/Home/PressRelease/5361
3. Pringsheim T, Smith DB, Tanveer S, et al. Systematic Review of Pharmacologic Treatment for Migraine Prevention in Adults: Report of the AAN Guidelines Subcommittee and the American Headache Society. Neurology. 2026;107(7):e218112. doi:10.1212/WNL.0000000000218112