Migraine Treatment Guidelines

Introduction to Migraine Treatment

The U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline recommends against the use of gabapentin for the prevention of episodic migraine (weak against recommendation) 1, 2
The American College of Physicians recommends strong consideration for triptans or combination of sumatriptan and naproxen for acute treatment of migraine 1, 3
The American Academy of Family Physicians suggests a weak recommendation for simple analgesics like acetaminophen, aspirin, ibuprofen, or naproxen for acute treatment of migraine 1, 4

The American Headache Society recommends a strong option for aspirin-acetaminophen-caffeine combination for acute treatment of migraine 1
The American College of Physicians recommends a weak option for newer CGRP antagonists (rimegepant, ubrogepant) for acute treatment of migraine 1

The American Heart Association recommends a strong option for candesartan or telmisartan for migraine prevention 1
The American Academy of Neurology recommends a strong option for CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) for migraine prevention 1
The U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline recommends a weak option for topiramate for migraine prevention 1
The American College of Physicians recommends a weak option for propranolol for migraine prevention 1, 5
The American Academy of Family Physicians recommends a weak option for valproate for migraine prevention 1, 6

The International Headache Society recommends determining migraine pattern, with episodic migraine defined as less than 15 headache days per month and chronic migraine defined as 15 or more headache days per month 5, 8
The American Headache Society recommends considering prevention if patient has two or more attacks per month with disability lasting 3+ days, contraindication to or failure of acute treatments, use of acute medications more than twice weekly, or presence of uncommon migraine conditions 1, 5, 8

The American Academy of Neurology recommends limiting use of acute medications to avoid medication overuse headache, with simple analgesics limited to less than 15 days/month and triptans limited to less than 10 days/month 7
The American College of Physicians recommends monitoring for adverse effects, especially with preventive medications that require long-term use 6

The American Academy of Family Physicians recommends considering amitriptyline for patients with both migraine and tension-type headache, as it may be more effective than beta-blockers 6
The American Headache Society recommends considering onabotulinumtoxinA injections for chronic migraine 1, 7
The American College of Physicians recommends considering non-pharmacological approaches such as biofeedback, cognitive-behavioral therapy, or exercise for patients with contraindications to first-line treatments 7