Neurology AdvisorAAN, AHS Update Pharmacologic Migraine Prevention Guidelines

✅ Guideline Update

The American Academy of Neurology and American Headache Society updated their migraine prevention guidance based on a systematic review of evidence through June 2024. The recommendations provide an evidence-based framework for deciding when preventive therapy should be offered, selecting among oral, injectable, and biologic treatments, managing special populations, addressing medication overuse, and determining when preventive therapies should be modified or discontinued. Shared decision-making is emphasized throughout the treatment process, with therapy selection guided by efficacy, tolerability, comorbidities, patient preferences, reproductive considerations, and cost.

Clinical Considerations

• Preventive treatment should be offered to patients with ≥4 migraine days per month, ≥4 moderate-to-severe headache days monthly, or substantial migraine-related disability.
• For efficacy-focused patients, recommended options include atogepant, CGRP monoclonal antibodies, propranolol, topiramate, valproate, and onabotulinumtoxinA for chronic migraine.
• For patients prioritizing tolerability, the guideline favors atogepant, eptinezumab, erenumab, fremanezumab, galcanezumab, and onabotulinumtoxinA for chronic migraine.
• Pregnancy counseling receives expanded emphasis, including avoidance of valproate and topiramate when possible, prioritization of nonpharmacologic therapies, and individualized risk-benefit discussions.
• Patients with medication-overuse headache should still be offered preventive therapy, with evidence supporting CGRP monoclonal antibodies, atogepant, onabotulinumtoxinA, and topiramate.
• Most preventive medications require 8 to 12 weeks at a therapeutic dose before efficacy assessment, while onabotulinumtoxinA requires approximately 24 weeks.

Practice Applications

• Discuss preventive treatment options with eligible patients experiencing frequent migraine or meaningful disability.
• Incorporate patient preferences, comorbidities, adverse-effect concerns, reproductive plans, and cost considerations into treatment selection.
• Monitor treatment response using standardized tools such as headache diaries, HIT-6, or MIDAS whenever feasible.
• Evaluate medication-overuse patterns and address them alongside preventive treatment strategies.
• Review benefits and risks of continuing versus tapering preventive therapy after sustained treatment response.