US Doctors Update Migraine Prevention Guidelines for First Time in 14 Years

For the first time in 14 years, the American Academy of Neurology (AAN) and the American Headache Society (AHS) have updated guidelines for preventing migraine attacks, publishing the recommendations August 31 in the journal Neurology. The previous version dated to 2012.

The update leans heavily on drugs that block calcitonin gene-related peptide (CGRP), a protein whose levels rise during a migraine attack. At least half a dozen CGRP-targeting medications, including erenumab (Aimovig) and fremanezumab (Ajovy), have been approved by the Food and Drug Administration (FDA) since 2012, given as tablets, injections or infusions. The guidelines credit them with reducing migraines in up to 70 percent of people who take them, with high tolerability.

For the first time, the guidelines also spell out who should be offered preventive treatment: people with at least four migraine or severe headache days a month, or whose migraines interfere with work or daily activities. An estimated 15 percent of Americans experience migraines, women disproportionately, and roughly 8 million U.S. adults meet the new criteria, though many do not realize it, said guideline co-author Rebecca Burch of the University of Vermont Medical Center.

Older options remain recommended too: beta-blockers such as propranolol, the antiseizure drug topiramate, and Botox for chronic migraine, defined as headache on 15 or more days a month for over three months. These carry longer safety records and lower costs than the newer CGRP drugs, and clinicians are advised to check whether treatment is working after eight to 12 weeks.

Andrew Charles of the UCLA Goldberg Migraine Program, not involved in the guidelines, said their complexity "is going to scare away primary care doctors." The guidelines also contain contradictions: topiramate is recommended for patients with a high body mass index, yet can cause birth defects and reduce hormonal birth control's effectiveness at higher doses, while candesartan, a hypertension drug used for migraine prevention, was rated as having insufficient evidence to support its use.