The American Academy of Neurology’s first migraine-guideline update since 2012 lowers the threshold for considering preventive care from eight monthly migraines to four and adds CGRP inhibitors as first-line options alongside traditional medicines.
Options include daily pills such as atogepant, topiramate, propranolol and amitriptyline; monthly CGRP injections such as erenumab, fremanezumab and galcanezumab; and eptinezumab infusions about every 12 weeks. CGRP-targeted treatments may be used alone or with other medicines. Botox, generally used for chronic migraine, is also given every 12 weeks.
Doctors generally need 8–12 weeks at a therapeutic dose to assess a medication; Botox can take about 24 weeks, or two treatment rounds. A headache diary can track migraine days, severity, missed activities and use of as-needed medication. Pregnancy or plans to become pregnant may affect treatment choices; some patients may consider exercise, trigger management, behavioral therapy or acupuncture without medication.
