Updated Guideline Guides Migraine Prevention Drug Selection

The American Academy of Neurology (AAN) and American Headache Society (AHS) have issued updated evidence-based recommendations on pharmacologic migraine prevention in adults. Published online in Neurology, the practice guideline addresses when preventive medication may be appropriate and how an initial therapy may be selected.

A multidisciplinary panel conducted a systematic review and developed the recommendations using the process described in the 2017 AAN Clinical Practice Guideline Process Manual. The review considered changes in the number of days with migraine, the proportion of individuals with a 50% or greater decrease in migraine attack days, and migraine-specific quality-of-life measures.

The guideline provides recommendations for deciding when to begin preventive pharmacotherapy, including consideration of migraine frequency and associated disability. It also emphasizes shared and informed decision-making when selecting treatment because the evidence does not establish a single preferred medication for every patient. The document addresses assessment of treatment effectiveness, adverse effects, and decisions about discontinuing preventive medication.

Medication selection is considered across several clinical circumstances and populations. The recommendations address adults with fibromyalgia, obesity, hypertension, or medication-overuse headache, as well as considerations for older adults. The panel also discusses pregnancy and lactation and other sex-related factors that may influence treatment choice.

The guideline authors frame preventive treatment as an individualized decision that incorporates evidence of benefit alongside contraindications, coexisting medical and psychiatric conditions, concurrent medications, and patient preferences regarding potential adverse effects. The update provides a structured framework for applying pharmacologic prevention across a range of adult migraine presentations without treating one option as universally appropriate.

Source: Oskoui M, Silsbee HM, Schwedt TJ, 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