The American Academy of Neurology and the American Headache Society have published updated practice recommendations on pharmacological migraine prevention in adults. The accompanying systematic review covers studies to June 2024. It appeared in Neurology at the end of August 2026.
The recommendations address when to start a preventive, which drug to choose, and how to choose in specific groups: people with fibromyalgia, obesity or hypertension, older adults, pregnancy and lactation, sex-related factors, and medication overuse. They also cover assessing response, managing adverse effects and when to stop.
The abstract does not list the individual recommendations, so check the full text before changing practice. What the scope signals is useful in itself: prevention is framed around comorbidity and life stage rather than a fixed drug ladder. In Indian practice, where CGRP-targeted drugs are costly and older oral preventives remain the mainstay, matching the drug to comorbidities is where most of the gain lies.
- Offer prevention when attacks are frequent or disabling, not only after acute treatment fails
- Choose a preventive that also treats a comorbidity, such as hypertension or obesity, where possible
- Plan for pregnancy before starting, particularly with valproate or topiramate
- Address medication overuse as part of starting prevention
- Set a review date to judge response and consider stopping
Why it matters
Migraine prevention guidance is now organised around the patient's comorbidities and life stage, not a single sequence of drugs.
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