2026 AAN/AHS Pharmacologic Treatment for Migraine Prevention in Adults Guideline Now Available

The American Academy of Neurology (AAN) and the American Headache Society (AHS) just published a new guideline regarding pharmacologic migraine prevention for adult patients. The guideline, Pharmacologic Treatment for Migraine Prevention in Adults, features recommendations for specific patient populations including pregnant patients, patients with fibromyalgia, among others. Additionally, recommendations are also provided for patients without significant comorbidities, along with recommendations on deciding when to start a preventive medication and when to assess treatment efficacy.

Today, we’re showcasing the recommendations included in the 2026 AAN/AHS guideline Pharmacologic Treatment for Migraine Prevention in Adults. View the full-text version of the guideline for the complete look at the recommendations, including the associated rationale.

Recommendations from the 2026 AAN/AHS Guideline Pharmacologic Treatment

Deciding to Start a Preventive Medication

• Clinicians should inform all patients with migraine that effective preventive treatments exist for frequent migraine attacks.
• Clinicians should offer preventive treatments to patients with migraine who experience ≥4 migraine days per month, or ≥4 moderate to severe headache days per month, to reduce headache frequency.
• Clinicians should offer preventive treatments to patients with substantial disability from migraine to reduce migraine-associated disability.

Shared Informed Decision Making

• Clinicians should inform patients of appropriate medication choices for migraine prevention, taking into account the patient's medical and psychiatric history, currently prescribed medications, and any contraindications to medications used for migraine prevention.
• Clinicians should discuss and understand the patient's preferences with respect to potential AEs of medications used for migraine prevention.
• Clinicians should discuss and understand the patient's preferences with respect to treatment modality (i.e., oral vs injectable).

Treatments for Patients Without Significant Cormorbidities or Specific Contraindications

• For patients for whom evidence of efficacy is the priority, clinicians should offer patients preventives with high or moderate confidence in the evidence for efficacy based on the SR.
  • Episodic migraine: atogepant, eptinezumab, erenumab, fremanezumab, galcanezumab, propranolol, topiramate, and valproate
  • Chronic migraine: atogepant, eptinezumab, erenumab, fremanezumab, galcanezumab, onabotulinumtoxinA, topiramate, and valproate
• For patients concerned about tolerability, clinicians should offer migraine preventives with fewer side effects.
  • Episodic migraine: atogepant, eptinezumab, erenumab, fremanezumab, and galcanezumab
  • Chronic migraine: atogepant, eptinezumab, erenumab, fremanezumab, galcanezumab, and onabotulinumtoxinA
• For patients concerned about possible long-term or unknown harms from medications, clinicians should offer migraine preventives that have been widely used for a long period of time while observing specific contraindications.
  • Episodic migraine: propranolol and topiramate
  • Chronic migraine: onabotulinumtoxinA and topiramate
• For patients concerned about cost, clinicians should offer less expensive preventive treatment options depending on the patient's specific pharmaceutical formulary plan and health care insurance system.
• For patients not responding to choices with higher confidence in the evidence, clinicians should offer migraine preventives with low confidence in the evidence for efficacy.
  • Episodic migraine: amitriptyline, flunarizine, metoprolol, pizotifen, rimegepant, and telmisartan

Treatment During Pregnancy and for Patients Planning Pregnancy

• People with migraine of childbearing potential who require migraine preventive therapy must be made aware of the potential risks to the fetus in the event of an unplanned pregnancy, and agents with known teratogenic effects (e.g., divalproex sodium, topiramate) should be avoided if possible.
• In people who are pregnant or planning a pregnancy, nonpharmacologic approaches that have the potential to reduce migraine attack frequency (e.g., behavioral interventions, acupuncture, exercise, trigger management) must be maximized.
• If pharmacologic migraine prevention is considered potentially necessary during pregnancy, it must be used only after a thorough discussion with the patient of the risks and alternatives, with joint decision making.
• If pharmacologic migraine prevention is necessary during pregnancy, clinicians must develop a strategy with the patient that limits overall pharmacologic exposures while maintaining the best possible migraine control.
• If a migraine preventive medication is considered necessary during pregnancy, clinicians should review the ACOG guideline medication recommendations and potential associated risks determined from their SR.
• If a migraine preventive drug is considered necessary during pregnancy, clinicians may offer nifedipine.
• If a migraine preventive drug is considered necessary during pregnancy and nifedipine is not an option or is ineffective, clinicians may offer metoprolol or propranolol, but the risks (i.e., cardiovascular abnormalities, cleft lip or palate, neural tube defects, and fetal growth retardation) must be balanced with the potential benefits.
• If a migraine preventive medication is considered necessary during pregnancy for chronic migraine, clinicians may offer onabotulinumtoxinA, but the risks must be balanced with the potential benefits. Extremely limited outcome data are available, and available data mainly pertain to preconception and first trimester exposures.

Treatment During Lactation

• To improve shared and informed decision making, clinicians must counsel patients who are lactating that migraine preventives pass into breast milk in varying amounts and can impact the health of breastfed infants, including counseling on the risks of specific medications based on evidence-based sources such as reference databases (e.g., LactMed).

Treatment Over the Adult Lifespan

• When prescribing a migraine preventive medication for older adults, depending on the drug being considered, the clinician should carefully assess for the presence of vascular disease, potential drug interactions, and reduced renal and/or hepatic function.
• Clinicians prescribing a migraine preventive medication with sedative potential for an older adult should discuss the possibility of side effects such as sedation and confusion and, if appropriate, initiate therapy with lower-than-usual doses.
• When choosing a preventive drug for an older adult, the clinician must discuss the possibility of hypotension or postural hypotension and, if appropriate, avoid drugs that significantly lower blood pressure or start therapy with lower-than-usual doses.
• Clinicians prescribing valproic acid for migraine prevention must notify female patients that it can increase the risk of PCOS.
• Clinicians prescribing topiramate for migraine prevention must notify female patients of childbearing potential that it can make hormonal contraception less effective at doses above 200 mg/d.
• Clinicians prescribing a migraine preventive for older adult male patients should evaluate whether there is risk of urinary retention and either avoid drugs with anticholinergic effects (e.g., amitriptyline) or discuss this possibility with the patient.

Treatments for Patients with Comorbid Medical and Psychiatric Conditions

• Clinicians should discuss with the patient with migraine who has a medical or psychiatric comorbidity whether it is preferable to treat both conditions with a single medication (combined approach) or to treat them both independently (independent approach).
• If a combined approach is chosen, efficacy and side effects should be closely monitored to determine whether the therapeutic approach should be switched to treating both conditions independently.

Treatments for Patients with Hypertension

• Clinicians may inform people with migraine and comorbid untreated hypertension that monotherapy options are available to treat both conditions, including enalapril, nifedipine, and telmisartan.

Treatments for Patients with Fibromyalgia

• Clinicians should offer amitriptyline for migraine prevention in patients with comorbid fibromyalgia.

Treatments for Patients with Increased Body Mass

• When an oral migraine preventive drug is being considered in a patient with increased body mass index, clinicians should offer topiramate.

Treatments for Patients with Medication Overuse

• Preventive medication should be offered to those with migraine who meet criteria for medication overuse.
• Preventive medication should be offered to those who have medication-overuse headache.
• Preventive medications that have evidence for efficacy in individuals with medication overuse or medication-overuse headache (e.g., CGRP [calcitonin gene−related peptide] monoclonal antibodies [mAbs], atogepant, onabotulinumtoxinA, and topiramate) should be considered before medications that lack such evidence.

Current Use of Acute Treatments

• When prescribing a migraine preventive medication, clinicians must evaluate the risk of drug interactions with a patient's migraine acute medications.
• When prescribing a migraine preventive medication, the clinician must evaluate the risk of side effects based on combining that preventive medication with the patient's migraine acute medications.

When to Assess Treatment Efficacy

• Clinicians should wait at least 8–12 weeks at the recommended tolerated dose of most medications for migraine prevention before assessing efficacy.
• Clinicians should wait 24 weeks at the recommended dose before assessing efficacy of onabotulinumtoxinA injections for migraine prevention before assessing efficacy.
• If suboptimal treatment response is observed by 8 weeks, physicians should optimize the dose of the medication for migraine prevention to the maximum tolerated dose or predetermined maximum based on efficacy studies.
• If no efficacy is observed after 8–12 weeks of treatment and other contributing factors are identified (e.g., inconsistent treatment adherence, frequent exposure to known triggers), physicians should engage in shared decision making with patients to continue an additional observation period.
• Clinicians should encourage continued lifestyle and trigger management in patients who take a medication for migraine prevention.
• If side effects are not tolerable, clinicians should consider a dose reduction.
• If side effects are not tolerable, clinicians should offer an alternative treatment option.
• If suboptimal response is observed after 12–24 weeks (see 14A and 14B), and other options are available and not contraindicated, clinicians should engage in shared decision making with the patient to initiate an alternate medication for migraine prevention.

Assessment of Treatment Efficacy

• Clinicians should document the frequency of migraine attacks to optimize assessment of treatment efficacy.
• Clinicians may use a measurement tool (e.g., headache diary, HIT-6, or MIDAS) consistently across patient visits to monitor efficacy and treatment response.
• Clinicians' assessment of treatment efficacy must be patient-centric and based on individual goals.
• Clinicians should utilize frequency, severity, migraine-associated symptoms, QOL, and use of acute therapy when assessing efficacy of treatment.

Counseling and Assessment of AEs

• Clinicians must provide counseling on common and serious or life-threatening AEs based on product monographs and drug information databases before prescribing migraine preventive medications.
• Clinicians must monitor patients for common and serious or life-threatening AEs as part of routine follow-up.

Stopping Preventive Therapy

• Clinicians should counsel patients that there is limited evidence that suggests a risk of increased headache days and decreased headache-related QOL after discontinuing a preventive medication.
• Clinicians should discuss the potential benefits and risks of tapering a migraine preventive medication after 6 months of treatment.

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