New Migraine Prevention Guidance Highlights CGRP Drugs, Broad Eligibility

The American Academy of Neurology and the American Headache Society have released new guidance aimed at helping doctors determine which migraine prevention drugs may be most effective for their patients. This is the first update to the guidelines since 2012, and it emphasizes the availability of new migraine-specific CGRP (calcitonin gene-related peptide) therapies. CGRP is a vasodilator believed to play a significant role in migraine pain.

Since the previous guidelines were published, there have been numerous treatment options for migraine prevention, including monoclonal antibodies targeting CGRP receptors, oral CGRP receptor antagonists, and traditional treatments like onabotulinumtoxinA, antiseizure medications, and beta-blockers. The new guidelines recommend migraine prevention treatments for individuals who experience four or more migraine days per month, or four or more moderate-to-severe headache days per month, or if migraine is negatively impacting their ability to work or perform daily tasks.

The guidelines distinguish between episodic and chronic migraine, which occurs 15 or more days per month with at least eight days exhibiting migraine features. For episodic migraine, galcanezumab and erenumab have shown high-confidence evidence of reducing headache frequency compared to placebo. Atogepant, eptinezumab, fremanezumab, propranolol, topiramate, and valproate have demonstrated benefits with moderate-confidence evidence.

For chronic migraine, high-confidence evidence suggests that fremanezumab, galcanezumab, and onabotulinumtoxinA lead to fewer headaches in patients. Moderate-confidence evidence supports benefits with atogepant, eptinezumab, erenumab, topiramate, and valproate. Both types of migraine have shown improvements in patient-reported quality-of-life outcomes, including erenumab, fremanezumab, galcanezumab, eptinezumab, rimegepant, atogepant, topiramate, and onabotulinumtoxinA.

The new guidelines also provide specific recommendations tailored to patients' priorities, such as effectiveness, side-effect profile, long-term safety, and cost. The research indicates that a variety of medications may effectively prevent migraine attacks and alleviate symptoms. If one medication is ineffective, there are still other options available. Burch, the lead author, emphasized that clinicians and patients should be aware of the numerous treatment options.

The update also addresses treatment during pregnancy, a topic not covered in previous guidance. Migraine is a chronic disease, and its impact on a person's life can fluctuate over time. It is the leading cause of disability worldwide, accounting for a significant number of disability-adjusted life-years. The guidelines aim to clarify which patients are eligible for preventive treatment, as many more patients with migraine are currently not receiving appropriate preventive care.