An overview of Pharmacologic Treatment for Migraine Prevention in Adults Practice Guideline Recommendations: Report of the AAN Guidelines Subcommittee and the American Headache Society (2026)
Background
The American Academy of Neurology (AAN) and American Headache Society (AHS) have updated their 2012 guideline on migraine prevention in adults. To develop their latest recommendations, they conducted a systematic review of over 200 randomized, controlled studies published through mid-2024.
Key Recommendations
- The authors encourage clinicians to consider patient priorities (e.g., tolerability and cost) and relevant comorbidities (e.g., hypertension) when choosing among medication options.
- For episodic migraine (<15 headache days/month), first-line medications include propranolol, topiramate, valproate, and the following calcitonin gene–related peptide (CGRP) inhibitors: atogepant, eptinezumab, erenumab, fremanezumab, galcanezumab.
- Second-line medications include amitriptyline, flunarizine, metoprolol, pizotifen, rimegepant, and telmisartan.
- For chronic migraine (≥15 headache days/month for >3 months, with migraine features on ≥8 days), first-line medications include topiramate, valproate, onabotulinumtoxinA, and the CGRP inhibitors listed above.
- If long-term safety is a priority, consider propranolol, topiramate, and onabotulinumtoxinA.
- In pregnant patients or patients who may become pregnant, valproate and topiramate are teratogenic and should be avoided. For these patients, the authors endorse nonpharmacological options and medications recommended by the American College of Obstetricians and Gynecologists, which include nifedipine, propranolol, metoprolol, and onabotulinumtoxinA (chronic migraine only).
- For hypertensive patients, consider use of enalapril, nifedipine, and telmisartan.
Comment
This guideline supports what we do in clinical practice, stratifying treatment options based on patient preferences and comorbidities. Additional guidance is provided on when to initiate, assess, modify, and discontinue preventive treatment. The cutoff point on the evidence review was in 2024, which meant that recent studies were excluded, including studies of rimegepant and candesartan, a good option for hypertensive patients. Not specified in these guidelines, CGRP inhibitors also should be avoided during pregnancy.
The American College of Physicians published a guideline on migraine prophylaxis last year, and it is worth noting one key difference: The AAN/AHS lists CGRP inhibitors as first-line options whereas the ACP recommends these drugs as second-line options. However, both guidelines acknowledge that CGRP inhibitors are probably at least as efficacious as other older drugs and that cost and insurance coverage remain significant barriers for many patients.