Medications to Reduce Headache Days in Migraine Patients

Chronic Migraine (≥15 Headache Days/Month)

The American College of Physicians recommends CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) as the most strongly recommended preventive medications for chronic migraine, reducing monthly migraine days by approximately 2-3 days 1, 2
The American Headache Society suggests that CGRP monoclonal antibodies reduce monthly migraine days by approximately 0.8-2.3 days compared to placebo 1, 3
The American College of Physicians notes that erenumab may increase the risk for development or worsening of hypertension, requiring blood pressure monitoring 1, 3
The American Academy of Neurology recommends onabotulinumtoxinA (Botox) as a second-line option for chronic migraine, reducing headache days by 1.8-1.9 days per month compared to placebo 1, 4, 5

The American Academy of Neurology recommends beta-blockers (propranolol, metoprolol, atenolol, or bisoprolol) as first-line options for episodic migraine 2
The American Headache Society suggests that topiramate has a "weak for" recommendation with reduction of 1.1 monthly migraine days versus placebo 1
The American College of Physicians recommends candesartan as a first-line option for episodic migraine prevention 2
The American Academy of Neurology notes that valproate has a "weak for" recommendation for episodic migraine prevention, but is absolutely contraindicated in women of childbearing potential due to teratogenicity 1, 2

The American Headache Society recommends determining migraine frequency to guide treatment, with ≥15 headache days/month indicating chronic migraine and <15 headache days/month indicating episodic migraine 5, 6, 2
The American College of Physicians suggests starting with CGRP monoclonal antibodies (erenumab, fremanezumab, or galcanezumab) for chronic migraine if accessible and affordable, and reserving onabotulinumtoxinA for patients who have failed or cannot access CGRP antibodies 1, 4, 5
The American Academy of Neurology recommends starting with beta-blockers (propranolol preferred), topiramate, or candesartan for episodic migraine, and reserving CGRP antibodies for patients failing 2-3 oral preventives 2, 3

The American Headache Society warns against using onabotulinumtoxinA for episodic migraine, as it is ineffective and wastes resources 1, 5
The American College of Physicians notes that valproate is absolutely contraindicated in women of childbearing potential due to teratogenicity 2
The American Academy of Neurology recommends monitoring blood pressure with erenumab due to increased hypertension risk 1
The American Headache Society suggests addressing medication overuse headache concurrently with preventive therapy, not sequentially 5