National Migraine and Headache Awareness Month, observed in June, is an annual event that highlights the importance of utilizing evidence-based strategies when crafting patient-centered treatment plans for individuals grappling with headaches and migraines. With headaches ranking the 5th most common reason for emergency department visits, it is no surprise that the CDC estimates migraine disorder alone affects nearly 18% of women and 6% of men, totaling approximately 40 million individuals. Given the lifetime prevalence of headache disorders exceeding 60%, addressing migraine and headache management through an evidence-based, shared decision-making approach is crucial to support the millions affected daily by these conditions.
This article provides a comprehensive, comparative analysis of recommended treatment and management approaches proposed in 6 different clinical practice guidance documents published by the American Headache Society (AHS), the Department of Veterans Affairs and the Department of Defense (VA/DoD), and the American Academy of Neurology (AAN). By analyzing and comparing their recommended management approaches, we aim to shed light on best practices for managing migraine headaches and headache and highlight the benefits of harmonizing guideline recommendations to provide effective and compassionate patient-centered care.
Guideline Synopsis:
American Academy of Neurology (AAN)
- “Practice guideline update summary: Botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache”
- Published April 2016
- Target Population:
- Patients with blepharospasm, cervical dystonia (CD), spasticity, and headaches
- Goal:
- To update the 2008 AAN guidelines for the use of botulinum neurotoxin (BoNT) in managing 4 new indications: blepharospasm, cervical dystonia (CD), spasticity, and headaches.
- Graded Level of Evidence: Yes
- Graded Strength of Recommendation: Yes
- Based on Systematic Review: Yes
- Literature Search Through: Not explicitly reported.
- Internal Review Conducted: Yes
- External Review Conducted: Yes
- Funding Source and COIs Disclosed: Yes
- Full text
- Guideline process manual
American Headache Society (AHS):
- “Calcitonin gene-related peptide-targeting therapies are a first-line option for the prevention of migraine: An American Headache Society position statement update.”
- Published March 2024
- Target Population:
- Patients 18 years of age or older experiencing chronic or episodic migraines with or without aura with appropriate indications for preventive migraine therapy.
- Goal:
- To update previous AHS consensus statements based on new evidence regarding the efficacy, safety, and tolerability of CGRP-targeting therapies for migraine prevention, including mAbs erenumab, eptinezumab, fremanezumab, and galcanezumab, and the small molecules (“gepants”) rimegepant and atogepant.
- Graded Level of Evidence: No
- Graded Strength of Recommendation: No
- Based on Systematic Review: No
- Literature Search Through: Not reported.
- Internal Review Conducted: Yes
- External Review Conducted: No
- Funding Source and COIs Disclosed: Yes
- Full text
- Pocket guide/ summary
The Department of Veterans Affairs and the Department of Defense (VA/DoD):
- “VA/DoD Clinical Practice Guideline for Management of Headache”
- Published September 2023
- Target Population:
- Patients eligible for care in the CA or DoD healthcare delivery systems, including veterans, active-duty service members and their dependents, who are living with headaches and receive care from community-based clinicians.
- Goal:
- To update the 2023 reiteration of VA/DoD Headache CPGs by providing more rigorously assessed recommendations and an evidence-based framework for evaluating and managing care in individuals living with headaches to improve clinical outcomes. d Level of Evidence: Yes
- Graded Strength of Recommendation: Yes
- Based on Systematic Review: Yes
- Literature Search Through: August 16, 2022
- Internal Review Conducted: Yes
- External Review Conducted: Yes
- Funding Source and COIs Disclosed: Yes
- Full text
- Pocket guide/ summary
- Toolkit
American Headache Society (AHS)
- “The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice."
- Published June 2021
- Target Population:
- All adult patients with a confirmed diagnosis of migraine with appropriate indications for the trial of acute pharmacological and/or nonpharmacologic treatment.
- Goal:
- To improve outcomes among adult patients with migraine who have unmet needs by helping clinicians identify and develop successful, evidence-based treatment plans for those most likely to benefit from a trial of a new therapy.
- Note from authors: “Although it provides timely recommendations to clinicians and their patients with migraine, this Consensus Statement is not intended to be, and should not be understood or applied as, a Clinical Practice Guideline.”
- Graded Level of Evidence: No
- Graded Strength of Recommendation: No
- Based on Systematic Review: No
- Literature Search Through: December 2018 to February 2021
- Internal Review Conducted: Yes
- External Review Conducted: Yes
- Funding Source and COIs Disclosed: Yes
- Full text
American Academy of Neurology (AAN) and the American Headache Society (AHS)
- “Practice Guideline Update: Acute Treatment of Migraine in Children and Adolescents"
- Published August 2019
- Target Population:
- Children and adolescents ages 0 to 18 years of age with pediatric migraines, which include at least 5 headaches over the past year that last 2–72 hours when untreated, with 2 of 4 additional features (pulsatile quality, unilateral, worsening with activity or limiting activity, moderate to severe in intensity), and association with at least nausea, vomiting, photophobia, or phonophobia.
- Goal:
- To update the 2004 ‘treatment of migraine in children’ guidelines by providing recommendations for the use of acute self-administered migraine treatments in children and adolescents to help reduce headache pain and associated symptoms (nausea, vomiting, photophobia, and phonophobia), and maintain headache freedom.
- Graded Level of Evidence: Yes
- Graded Strength of Recommendation: Yes
- Based on Systematic Review: Yes
- Literature Search Through: December 2003 to August 2017
- Internal Review Conducted: Yes
- External Review Conducted: Yes
- Funding Source and COIs Disclosed: Yes
- Full text
American Academy of Neurology (AAN) and the American Headache Society (AHS)
- “Practice guideline update summary: Pharmacologic treatment for pediatric migraine prevention"
- Published August 2019
- Target Population:
- Children 3 years to 18 years of age with migraines, including special populations of sexually active adolescents who were of childbearing age.
- This does not include patients with episodic syndromes that may be associated with migraine, including cyclic vomiting, abdominal migraine, benign paroxysmal vertigo, and benign paroxysmal torticollis.
- Goal:
- To provide updated evidence-based recommendations for migraine prevention using pharmacologic treatment with or without cognitive behavioral therapy in the pediatric population.
- Graded Level of Evidence: Yes
- Graded Strength of Recommendation: Yes
- Based on Systematic Review: Yes
- Literature Search Through: January 2003 to August 2017
- Internal Review Conducted: Yes
- External Review Conducted: Yes
- Funding Source and COIs Disclosed: Yes
- Full text
| Drug Name | AAN/AHS Acute treatment of migraine in children and adolescents | AAN/AHS Pharmacologic treatment for pediatric migraine prevention |
| ibuprofen (OS) | Recommended (7.5–10 mg/kg per dose) as an initial treatment to reduce pain in children and adolescents with migraine. In adolescents whose migraine is incompletely responsive to a triptan, ibuprofen (or naproxen) should be offered as adjuvant therapy to a triptan-containing medication regimen. Healthcare providers should counsel patients and families to use no more than 14 days of ibuprofen per month to help reduce the risk of rebound (medication overuse) headaches. | Recommended for children and adolescents with frequent headache- or migraine-related disability. Note: taking over-the-counter simple analgesics for more than 14 days in a month can lead to medication overuse headaches. |
| acetaminophen (OS) | Recommended (15 mg/kg per dose) for acute migraine pain relief in children. Healthcare providers should counsel patients and families to use no more than 14 days of acetaminophen per month .to help reduce the risk of rebound (medication overuse) headaches." | |
| Triptans | ||
| Combination sumatriptan /naproxen (OT) | Recommended for patients aged 12 years and older (10/60, 30/180, 85/500 mg) Triptans are not to be prescribed for those with contraindications, including those with a history of ischemic vascular disease or accessory conduction pathway disorders. | Recommended for children and adolescents with frequent headache- or migraine-related disability. Note: taking triptans, ergotamines, opioids, and combination analgesics on more than 9 days in a month can lead to medication overuse headache. |
| sumatriptan (NS) | Recommended for patients aged 12 years and older 20 mg | |
| rizatriptan (ODT) | Recommended for patients aged 6-17 years (5-10 mg) Triptans are not to be prescribed for those with contraindications, including those with a history of ischemic vascular disease or accessory conduction pathway disorders. | |
| almotriptan (OT) | Recommended for patients aged 12 years and older (6.25 or 12.5 mg) Triptans are not to be prescribed for those with contraindications, including those with a history of ischemic vascular disease or accessory conduction pathway disorders. | |
| zolmitriptan (NS) | Recommended for patients aged 12 years and older (5 mg) Triptans are not to be prescribed for those with contraindications, including those with a history of ischemic vascular disease or accessory conduction pathway disorders. | |
| Antiemetics | Recommended for children and adolescents with migraine with prominent nausea or vomiting symptoms associated. | Not discussed |
| amitriptyline | Not discussed | Amitriptyline combined with CBT is recommended after informing the patients and care givers of the potential side effects of amitriptyline, including the black box warning of increased risk of suicidal thoughts and behaviors in children, adolescents, and young adults. |
| topiramate or valproate | Not discussed | Recommended after discussing the side effects. Topiramate and valproate can cause teratogenic effects if used in patients of childbearing potential. Topiramate at a daily dose of 200 mg or less does not interact with oral combined hormonal contraceptives. Higher doses have been associated with decreased effectiveness. |
| propranolol | Not discussed | Recommended after discussing potential side effects |
| Cognitive Behavioral Therapy | Not discussed | Amitriptyline combined with CBT is recommended after informing the patients of the potential side effects of amitriptyline, including the black box warning of increased risk of suicidal thoughts and behaviors in children, adolescents, and young adults. |
| Counseling, Lifestyle, and Behavioral Modifications | Recommended | Recommended |
| Screening and management for anxiety | Not discussed | Recommended |
| NS, nasal spray; NSAID, non-steroidal anti-inflammatory drug; ODT, oral disintegrating tablet; OS, oral solution; OT, oral tablet; SSRA, selective serotonin receptor agonist | ||
Headache & Migraine in Adult: Comparing Treatment and Prevention Recommendations
| Intervention | AAN Botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache | AHS Calcitonin gene-related peptide-targeting therapies are a first-line option for the prevention of migraine | VA/DoD The VA/DoD clinical practice guideline for the management of headache | AHS Update on integrating new migraine treatments into clinical practice |
| Pharmacological Intervention | ||||
| onabotulinumtoxinA (OnaBoNT-A) Brand name Botox | Recommended to increase headache-free days. Probably improves health-related quality of life in chronic migraine. Ineffective for episodic migraine. Is probably ineffective for chronic tension headaches. | Recommended for chronic migraine prevention | Suggested for the prevention of chronic migraine Suggested against for the prevention of episodic migraine Suggested against botulinum/neurotoxin injection for the prevention of chronic tension-type headache | Required to be tried before CGRP. Established efficacy for migraine prevention. Probably effective if combined with CGRP mAb. |
| Calcitonin gene-related peptide (CGRP)-targeting treatments | ||||
| The Monoclonal Antibodies (mAbs) | ||||
| erenumab | Not discussed | Recommended for both episodic and chronic migraine prevention | Recommended for the prevention of episodic or chronic migraine | Monoclonal antibodies are effective in migraine prevention |
| fremanezumab | Not discussed | Recommended for both episodic and chronic migraine prevention | Recommended for the prevention of episodic or chronic migraine | |
| galcanezumab | Not discussed | Recommended for both episodic and chronic migraine prevention | Recommended for the prevention of episodic or chronic migraine Suggested for the prevention of episodic cluster headache Suggested against for the prevention of chronic cluster headache | |
| eptinezumab | Not discussed | Recommended for both episodic and chronic migraine prevention | Intravenous eptinezumab is suggested for the prevention of episodic or chronic migraine. | |
| Gepants: | ||||
| rimegepant | Not discussed | Recommended for both episodic and chronic migraine prevention | Neither for nor against for prevention of episodic migraine due to insufficient evidence Suggested for acute treatment of migraine | Gepants are effective in acute migraine treatment |
| atogepant | Not discussed | Recommended for both episodic and chronic migraine prevention | Suggested for the prevention of episodic migraine | |
| ubrogepant | Not discussed | Not discussed | Suggested for the acute treatment of migraine | |
| Triptans | ||||
| eletriptan frovatriptan rizatriptan sumatriptan (PO or sub-Q) Combination sumatriptan/naproxen zolmitriptan (PO or NS) | Not discussed | Not discussed | Eletriptan, frovatriptan, rizatriptan, sumatriptan (oral or subcutaneous), the combination of sumatriptan and naproxen, or zolmitriptan (oral or intranasal) are recommended for the acute treatment of migraine. Subcutaneous sumatriptan (6 mg) or intranasal zolmitriptan (10 mg) are suggested for the acute treatment of cluster headache. | Triptans are effective in acute migraine treatment When acute treatment does not bring relief or when oral tablets cannot be used, options for outpatient rescue include subcutaneous SC sumatriptan and other drugs Frovatriptan established efficacy for migraine prevention |
| CNS-Acting Medications | ||||
| SSRIs: venlafaxine duloxetine | Not discussed | Venlafaxine and duloxetine are recommended for episodic and chronic migraine prevention | Neither for nor against venlafaxine due to insufficient evidence | Should be used as first line therapy prior to initiation of CGRP-related medications Venlafaxine is probably effective in migraine prevention |
| TCAs:: amitriptyline nortriptyline | Not discussed | Recommended for episodic and chronic migraine prevention | Amitriptyline is suggested for the prevention of chronic tension-type headache | Should be used as first line therapy prior to initiation of CGRP-related medications Amitriptyline is probably effective in migraine prevention |
| lasmiditan | Not discussed | Not discussed | Neither for nor against for acute migraine treatment due to insufficient evidence | Effective in acute migraine treatment |
| memantine | Not discussed | Not discussed | Suggested for the prevention of episodic migraine. | Probably effective in migraine prevention |
| topiramate | Not discussed in the recommendations | Recommended for episodic and chronic migraine prevention | Suggested for the prevention of episodic and chronic migraine | Established efficacy in migraine prevention Required to be tried before CGRP |
| divalproex sodium/ valproate sodium | Not discussed | Divalproex sodium/ Valproate sodium are recommended for episodic and chronic migraine prevention | Valproate is suggested for the prevention of episodic migraine. | Both established efficacy in migraine prevention |
| Ergot alkaloids | ||||
| dihydroergotamine ergotamine ergotamine derivatives | Not discussed | Not discussed | Not discussed in the recommendations but mentioned elsewhere | Ergotamine is probably effective Ergotamine derivatives are effective Other forms of dihydroergotamine than ergotamine derivatives are probably effective for acute migraine treatment |
| Anti-Emetics | ||||
| metoclopramide | Not discussed | Not discussed | Neither for nor against intravenous metoclopramide due to insufficient evidence | Probably effective in acute migraine treatment |
| prochlorperazine | Not discussed | Not discussed | Neither for nor against intravenous prochlorperazinedue to insufficient evidence | Probably effective in acute migraine treatment |
| Beta-blockers | ||||
| metoprolol propranolol timolol atenolol nadolol | Not discussed | Metoprolol, propranolol, timolol, atenolol, nadolol are recommended for episodic and chronic migraine prevention | Propranolol is suggested for the prevention of migraine | Should be used as first line therapy prior to initiation of CGRP-related medications Propranolol, metoprolol, and timolol established efficacy in migraine prevention Atenolol and nadolol are probably effective in migraine prevention |
| ACEi/ARBs | ||||
| candesartan | Not discussed | Recommended for episodic and chronic migraine prevention | Candesartan or telmisartan are recommended for the prevention of episodic migraine. | Established efficacy in migraine prevention |
| lisinopril | Not discussed | Not discussed | Suggested for the prevention of episodic migraine | Probably effective in migraine prevention |
| Miscellaneous | ||||
| Analgesics/NSAIDs: ibuprofen aspirin naproxen celecoxib diclofenac flurbiprofen IV ketoprofen IV &IM ketorolac acetaminophen | Not discussed | Not discussed | Aspirin/acetaminophen/caffeine are recommended for the acute treatment of migraine. Acetaminophen, aspirin, ibuprofen, or naproxen are suggested for the acute treatment of migraine. Ibuprofen (400 mg) or acetaminophen (1,000 mg) are suggested for the acute treatment of tension-type headache. | Aspirin, celecoxib oral solution, diclofenac, ibuprofen, and naproxen are effective in acute migraine treatments Flurbiprofen, ketoprofen, IV, and IM ketorolac are probably effective in acute migraine treatment Acetaminophen + aspirin + caffeine is effective in acute migraine treatment |
| PO magnesium | Not discussed | Not discussed | Oral magnesium is suggested for the prevention of migraine | Not discussed |
| IV magnesium | Not discussed | Not discussed | Not discussed | IV magnesium is probably effective in acute migraine treatment |
| IV ketamine | Not discussed | Not discussed | Suggested against for the acute treatment of migraine | Not discussed |
| Normobaric oxygen | Not discussed | Not discussed | Suggested for the acute treatment of cluster headache | Not discussed |
| Procedural interventions | ||||
| Greater occipital nerve block | Not discussed | Not discussed | Suggested for the acute treatment of migraine Neither for or against for the prevention of chronic migraine due to insufficient evidence | Not discussed |
| Non-invasive Vagus Nerve Stimulation | Not discussed | Not discussed | Suggested for the acute treatment of episodic cluster headache | May be appropriate for acute and/or preventive treatment |
| Implantable Sphenopalatine Ganglion Stimulator | Not discussed | Not discussed | Suggested against for the treatment of cluster headache | Not discussed |
| Neuromodulation devices | Not discussed | Not discussed | Neither for or against due to insufficient evidence | A neuromodulation 4 device may be appropriate for acute migraine treatment only (remote electrical neuromodulation) |
| Non-pharmacologic, non-procedural interventions | ||||
| Behavioral interventions | Not discussed | Not discussed | Neither for nor against due to insufficient evidence | Effective to prevent migraine |
| Aerobic exercise or progressive strength training | Not discussed | Not discussed | Suggested for prevention of tension-type and migraine headaches | Should be included in the personalized plans |
| Physical therapy | Not discussed | Not discussed | Suggested for the management of tension-type headache or migraine, or cervicogenic headache | Not discussed |
2: Episodic migraine (EM) refers to migraine with a lesser frequency of attack.
Key Takeaways: Headache & Migraine Management for Pediatric Patients
- Acute migraine treatments are more likely to be effective when used early in symptom onset while pain is still mild.
- A series of medication trials may be needed to find the prevention and treatment regimen that best fits a patient’s specific needs through shared decision making. Ibuprofen, acetaminophen (in children and adolescents), and triptans (mainly in adolescents) are recommended for the relief of acute migraine pain.
- Adolescents receiving sumatriptan/naproxen combination therapy or zolmitriptan nasal spray are more likely to be headache-free within 2 hours of administration.
- Acute treatments were not effective for migraine-related symptoms such as nausea or vomiting. However, some triptans were effective for symptoms like phonophobia and photophobia.
- The nonoral route is recommended when the headache pain rapidly peaks, is accompanied by nausea or vomiting, or if oral preparations fail to provide adequate pain relief.
- "The majority of preventive medications showed no superiority over placebo."
- Shared decision-making about the use of short-term treatment trials (a minimum of 2 months) is encouraged for those who may benefit from preventive treatment.
- Healthcare providers must not prescribe triptans to adult or pediatric patients with contraindications to this therapy, including those with a history of severe hepatic or renal impairment, those with Wolff-Parkinson-White syndrome or other arrhythmias associated with accessory conduction pathway disorders, ischemic bowel disease, and/or patients who have or are at risk of developing ischemic vascular disease, including coronary artery disease, peripheral vascular disease, cerebrovascular disease, stroke, or with uncontrolled hypertension.
Key Takeaways: Headache & Migraine Management for Adults
- Preventive therapy is a crucial component in the management of headaches and migraines.
- For migraines,
- Interventions for the prevention and treatment of migraines include pharmacotherapies, neuromodulation, behavioral interventions, procedures, and injections.
- Other modalities including relaxation therapies, acceptance and commitment therapy, and mindfulness-based therapies may be effective for migraine prevention and/or as an adjunctive treatment.
- Insufficient evidence exists regarding the effectiveness of acupuncture, dry needling, or yoga for treating or preventing migraine headaches.
- There are 4 US FDA-approved preparations of botulinum neurotoxin (BoNT), with onabotulinumtoxinA (onaBoNT-A) indicated for use in migraine headache management.
- For migraine prevention, CGRP-targeting therapies include the mAbs (erenumab, fremanezumab, galcanezumab, and eptinezumab) and the small-molecule CGRP receptor antagonists (gepants).
- Rimegepant and atogepant are recommended first-line agents for migraine prevention.
- Note: Although the CGRP-targeting therapies have been in clinical use for 5 years, continuous monitoring for potential adverse effects is highly encouraged.
- Insufficient evidence exists regarding the effectiveness of coenzyme Q10, feverfew, melatonin, omega-3, vitamin B2, vitamin B6, fluoxetine, levetiracetam, and verapamil for preventing migraine headaches.
- For cluster headaches,
- Galcanezumab is recommended for preventing episodic cluster headaches. It is suggested against for the prevention of chronic cluster headaches.
- Acute treatments include sub-q sumatriptan, intranasal zolmitriptan, normobaric oxygen, and non-invasive vagus nerve stimulation.
- For tension headaches,
- OTC analgesics like ibuprofen and acetaminophen were recommended for acute treatment.Amitriptyline, physical therapy, aerobic exercise and progressive strength training were recommended for prevention of chronic tension-type headaches.
- Botox was recommended against for prevention of chronic tension-type headaches.
By continually educating ourselves and aligning with evidence-based practices, we enhance our ability to support those in need and contribute to improving patients' quality of life, ameliorated from the impacts of migraines and headaches.
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