Migraine Prevention

 New Migraine Prevention Guidelines - Q&A

Q: What is new?
A: The American Academy of Neurology and the American Headache Society released new prevention guidelines on August 31, 2026. The old ones were from 2012. The biggest change is they now include newer, migraine-specific drugs that block a protein called CGRP, which helps trigger migraines. These are pills like atogepant (Qulipta) and shots like eptinezumab (Vyepti), erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emgality).

Q: Who should think about taking a preventive medicine?
A: Anyone with migraine should be told that prevention exists. You should be offered it if you have:

  • 4 or more migraine days per month, OR
  • 4 or more days per month with moderate-to-severe headaches, OR
  • Migraines that really interfere with your work, family, or daily life.

Prevention can mean fewer headache days and less disability, and may help stop occasional migraines from becoming chronic. Right now, many people who could benefit aren't getting it.

Q: Which preventive drug is the best?
A: There is no single best drug for everyone. The choice should be made together with your doctor based on your health history, other conditions, what side effects you can tolerate, whether you prefer a pill or a shot, and cost/insurance.

Q: What are the options?
A: It depends on what matters most to you:

  • If you want the strongest evidence for effectiveness: For occasional migraine (episodic), options include the CGRP drugs, plus older drugs propranolol, topiramate, and valproate. For chronic migraine (15+ headache days a month), the list is similar but includes Botox (onabotulinumtoxinA) injections instead of propranolol.
  • If you are most worried about side effects: CGRP drugs and Botox tend to be easier to tolerate.
  • If you are worried about long-term or unknown risks: Older drugs that have been used for many years like propranolol, topiramate, and Botox may be preferred.

Q: How long do I have to try a drug before I know if it works?
A:

  • For most pills and CGRP shots: 8 to 12 weeks at the proper dose.
  • For Botox: 24 weeks, which is 2 rounds of shots.
    If it's not helping enough after that and you have other options, you and your doctor should talk about switching.

Q: What if I have other health problems too?
A: Your doctor should look for a drug that can help both. For example, amitriptyline might be suggested if you have migraine and fibromyalgia. Topiramate might be considered if you would like to avoid weight gain. Even if you have medication-overuse headache from taking pain relievers too often, you should still be offered prevention.

Q: What about pregnancy?
A: This was a big focus of the new guidelines.

  • If you could become pregnant, your doctor should counsel you about risks if you became pregnant unexpectedly.
  • Drugs that can cause birth defects, like valproate/divalproex sodium and topiramate, should be avoided when possible.
  • If you are pregnant or planning pregnancy, try non-drug approaches first: behavioral strategies, acupuncture, exercise, and trigger management.
  • If you do need medicine while pregnant, nifedipine (a blood pressure medicine) is considered first choice.
  • If that doesn't work, metoprolol or propranolol may be considered after weighing risks and benefits.
  • For chronic migraine, Botox may be considered, but there is very little safety information in pregnancy.

Q: What should I do next?
A: If you have frequent or disabling migraines, ask your doctor if prevention might be right for you and which option fits your priorities best.

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