The American Academy of Neurology and the American Headache Society published a joint guideline on preventing migraine in adults on August 31, 2026, in the journals Neurology and Headache. It covers when to start a preventive medication, which drugs to use, and how to judge whether a drug is working.
Key takeaways
- The guideline sets out when to start a preventive medication and which drugs to use.
- The strongest evidence went to newer CGRP-targeting drugs and to Botox for chronic migraine, but propranolol and topiramate, both decades old, sit on the same list.
- The evidence search closed on June 6, 2024, so the guideline is already behind on some newer trial data.
What the guideline says
The recommendations rest on a systematic review of randomized trials from MEDLINE, Embase and ClinicalTrials.gov through June 6, 2024.
For episodic migraine, moderate-confidence evidence supported atogepant, eptinezumab, fremanezumab, propranolol, topiramate and valproate.
For chronic migraine, moderate-confidence evidence supported atogepant, eptinezumab, erenumab, topiramate and valproate.
The guideline carries separate advice for people with fibromyalgia, obesity or hypertension, for older adults, for pregnancy and lactation, and for people who are overusing acute pain medication. It also makes recommendations on how to assess whether a treatment is working.
Dr. Kumar’s take
The headline everyone will write is that CGRP drugs won. Read the actual lists and something more useful shows up. Propranolol, an old beta blocker, and topiramate, an anti-seizure drug, sit in the same moderate-confidence tier as three of the new injectables. The guideline is not ranking old drugs below new ones. It is ranking the evidence.
That matters because the review states plainly that evidence comparing active treatments was limited and generally of low or very low confidence. Nobody has shown in a fair head-to-head trial that a monthly injection beats a cheap generic pill. So the honest conversation is about cost, insurance step therapy and which side effects a person can live with, not about novelty.
Two things a wire summary will miss.
First, the cutoff. The search closed June 6, 2024, and the guideline published more than two years later. Candesartan, an inexpensive blood pressure generic often used for migraine, was marked as having insufficient evidence to support its use. Co-author Tamara Pringsheim told STAT News that a large study with positive results was published after the cutoff and was not included. A guideline is a snapshot, not a live feed. That limitation is built into how systematic reviews and evidence syntheses work.
Second, the four-day threshold moves a very large group from “manage it yourself” into “candidate for prevention.” Many of those people have been treating attacks with over-the-counter painkillers, which is the exact pattern behind medication-overuse headache, where the treatment starts causing the headaches. Guideline co-author Rebecca Burch said the goal was to be clear about who is eligible, and that it is more people than are getting preventive treatment now. Many will still hit a prior authorization wall.
Complexity is a real risk here. Andrew Charles of the UCLA Goldberg Migraine Program, who was not on the panel, told STAT News the layered recommendations are “going to scare away primary care doctors from using it because of how complicated it is.” Most migraine is handled in primary care, not in neurology offices.
What it means for you
Count your headache days for a month before your next appointment. Note how many were moderate or severe, and how many kept you from working. That number, not how bad the worst attack felt, is what the guideline runs on.
If you cross four days a month, prevention is on the table, and there are inexpensive options as well as expensive ones.
If you are reaching for over-the-counter pain medication often, say so. The guideline has separate recommendations for people with medication overuse, and that changes the plan.
If the first preventive drug does not work, a different class may still help. The guideline includes recommendations on how to judge whether a drug is working.