The guidelines recommend offering preventive treatment to people who have at least four migraine or severe headache days per month, or whose migraines interfere with their ability to work or complete daily tasks. The guidelines recommend offering preventive treatment to people who have at least four migraine or severe headache days per month, or whose migraines interfere with their ability to work or complete daily tasks. Approximately 8 million adults in the United States meet the criteria for preventive migraine treatment under the new guidelines.

About one-third of the guideline panel members had relevant conflicts of interest and were not allowed to rate or review evidence, but voted on the recommendations. The systematic review and practice guideline recommendations were published in the journals Neurology and Headache. The American Academy of Neurology is a professional society representing neurologists and neuroscientists.

The guidelines give high marks for efficacy and tolerability to the CGRP-targeting medications atogepant (Qulipta), eptinezumab (Vyepti), erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emgality). The Food and Drug Administration has approved at least six medications for migraine prevention since 2012. Many of the new migraine prevention medications approved since 2012 target the calcitonin gene-related peptide (CGRP) pathway.

The guidelines recommend CGRP-targeting medications as a preventive option for patients who frequently rely on acute pain medication. For episodic migraine, galcanezumab and erenumab outperformed placebo in reducing headache frequency with high-confidence evidence. For chronic migraine, high-confidence evidence indicated patients had fewer headaches with fremanezumab, galcanezumab, and onabotulinumtoxinA.

The guidelines include older treatments such as Botox for chronic migraine, propranolol for episodic migraines, and the anti-seizure drug topiramate. Chronic migraine is defined in the guidelines as headache on 15 or more days per month for over three months, with at least eight of those days including migraine features. Clinicians should assess treatment effectiveness after eight to 12 weeks, according to the guidelines.

The guidelines include separate recommendations for patients with high body mass index, fibromyalgia, hypertension, or who are pregnant. The guidelines recommend topiramate as an effective preventive migraine medication and as an option for patients with high BMI. Topiramate is known to cause birth defects and can make hormonal birth control less effective at higher doses.

The scientific review in the guidelines found amitriptyline to be a viable migraine treatment option for some pregnant patients. The American College of Obstetricians and Gynecologists advises against using tricyclic antidepressants during pregnancy due to the risk of major congenital abnormalities. The guidelines stated there was insufficient evidence to support the use of candesartan for migraine prevention based on evidence available as of mid-June 2024.

A large study with positive results for candesartan was published after the evidence synthesis cutoff date and was not included in the guidelines. The guidelines recommend rimegepant (Nurtec) for patients with episodic migraine only if they do not respond to medications with higher evidence. Rimegepant was approved by the FDA in 2021 as a preventive treatment for episodic migraine.

Rebecca Burch, neurologist at the University of Vermont Medical Center, said there has been a wealth of new treatment available and that studies of the U.S. population show many more patients with migraine are eligible.

Joanna Kempner, sociology professor at Rutgers University, said guidelines are one way that groups like the AAN and the AHS can help improve patient outcomes. She said a strong recommendation provides physicians with much-needed ammunition in their fights for prior authorization.

Andrew Charles, director of the UCLA Goldberg Migraine Program, expressed concern about the complexity of the new recommendations. He said he thinks it’s going to scare away primary care doctors from using it because of how complicated it is. He noted that payers will often find any reason they can to not approve access to a specific medication.

Why It Matters

The release of these guidelines marks the first update to migraine prevention standards in over a decade, reflecting changes in available treatments and clinical understanding. The expansion of eligibility criteria means millions more adults may now qualify for preventive therapies that were previously restricted to narrower patient groups.

The emphasis on CGRP-targeting medications represents a shift toward newer pharmacological options that have demonstrated high efficacy in recent trials. However, the detailed nature of the recommendations and the involvement of multiple medical societies show the ongoing challenges in standardizing care across different specialties and ensuring insurance coverage for these treatments.

Timeline

The previous migraine prevention guidelines from the American Academy of Neurology and the American Headache Society were published in 2012. The guideline development process began in January 2018.

The updated guidelines are based on a systematic review of 217 studies on migraine prevention drugs published through June 4, 2024. The American Academy of Neurology and the American Headache Society released updated guidelines for migraine prevention on August 31, 2026.

What's New

A study titled "Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurolo" was published in 2013 in Neurology. "The research shows many different types of medications may be effective for preventing migraine attacks and reducing symptoms." The hope is that this guideline helps clinicians feel more comfortable prescribing preventive treatments for people with migraine. "Clinical practice guidelines are an important resource for neurologists and other clinicians working to provide the best possible care for people with neurological conditions."

The American Academy of Family Physicians endorsed the updated migraine prevention guidelines. It was noted that newer treatment options have revolutionized the care for millions of people in the U.S. and worldwide.

How Sources Differ

Sources differ on the scope of migraine prevention evidence. Doi.org notes a study titled Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurolo was published in 2013 in Neurology, while the American Academy of Neurology and American Headache Society systematic review states the updated guidelines are based on a systematic review of 217 studies on migraine prevention drugs published through June 4, 2024.

Sources differ on the timing of migraine prevention updates. The Neurology journal August 31, 2026 issue reports the American Academy of Neurology and the American Headache Society released updated guidelines for migraine prevention on August 31, 2026, while the American Academy of Neurology and American Headache Society systematic review focuses on the underlying evidence base published through June 4, 2024.

Sources differ on the history of migraine prevention guidelines. The Neurology journal 2012 issue states the previous migraine prevention guidelines from the American Academy of Neurology and the American Headache Society were published in 2012, while the American Academy of Neurology and American Headache Society systematic review details the current evidence review process.

Sources differ on organizational responses to migraine prevention guidelines. The American Academy of Family Physicians endorsement statement confirms the American Academy of Family Physicians endorsed the updated migraine prevention guidelines, while the American Academy of Neurology and American Headache Society systematic review describes the evidence basis for the recommendations.

Sources differ on specific medication recommendations for migraine prevention. The American Academy of Neurology and American Headache Society systematic review outlines the broad evidence base, while the American Academy of Neurology and American Headache Society 2026 migraine preven guidelines stated there was insufficient evidence to support the use of candesartan for migraine prevention based on evidence available as of mid-June 2024.