Putting the Updated AAN/AHS Migraine Prevention Guideline Into Practice

In August 2026, the American Academy of Neurology (AAN) and American Headache Society (AHS) published an updated practice guideline on pharmacologic migraine prevention in adults, the organizations’ first update since 2012. The guideline was published simultaneously in Neurology and Headache.^1,2

The guideline recommends that clinicians offer preventive treatment to adults with 4 or more migraine days per month, 4 or more moderate to severe headache days per month, or migraine that substantially affects their ability to work or complete daily tasks.³ It also incorporates evidence for preventive treatments approved since the previous guideline, including calcitonin gene-related peptide (CGRP)–targeted therapies.

In a conversation with NeurologyLive^®, migraine specialist Ann Pakalnis, MD, clinical professor of neurology and pediatrics at The Ohio State University Wexner Medical Center, discussed how clinicians can navigate payer step therapy requirements. She also talked about how the lower threshold for prevention may affect referral patterns, how she evaluates whether a preventive treatment is working, and what the guideline does not address.

NeurologyLive: Prevention is now recommended for patients with 4 or more migraine days per month. How might that change who gets referred or treated earlier?

Ann Pakalnis, MD: With the recommendation changing to 4 migraine headache days a month, I think more patients will be referred to neurology, and to headache providers in particular. I think that will be a good thing, and hopefully it will open up more dialogue about the need for preventive medicine.

Many payers still require patients to try older medications before CGRP-targeted therapies. How should clinicians handle that, given the new guideline?

Unfortunately, many insurance payers still require patients to try older medications first through step therapy. We are active in writing letters of medical necessity and in forwarding current research articles, such as the guideline, for insurance payer review. Oftentimes, their recommendations lag behind recent recommendations in the literature to some extent. Sometimes we need to do peer-to-peer consultations with physicians from the insurance companies, and education there is also of paramount significance.

How do you evaluate whether a preventive treatment is working?

We evaluate medication effectiveness, adverse effects, and the patient’s level of disability from their headaches to determine whether a preventive is working. The gold standard previously was a 50% reduction in headache frequency with a preventive medicine.

What important questions does the guideline leave unanswered, and what research would you most like to see next?

The guideline did not address other therapies, such as medical devices for the treatment of migraine. Many have been approved by the FDA multiple years, have good safety data, and also seem to be very beneficial. Many of our patients are expressing increased interest in these.

Transcript edited for clarity. Click here for more of our headache and migraine coverage.

REFERENCES
1. 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
2. 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. Headache. 2026;66(9):1971-1990. doi:10.1111/head.70200
3. AAN and AHS issue updated guideline on migraine prevention medications for adults. News release. American Academy of Neurology. August 31, 2026. Accessed October 28, 2026. https://www.aan.com/PressRoom/Home/PressRelease/5361