A multidisciplinary panel of medical experts has published updated guidance on preventing migraines in adults, emphasizing that treatment decisions should be made collaboratively between doctors and patients. The recommendations, published in Neurology, were developed by a group that included medical specialists, research methodologists and patient advocates, with the American Academy of Neurology and the American Headache Society leading the effort that began in 2018.
The experts recommended that doctors offer daily preventive medicines to patients who experience four or more migraine days per month, or to those with significant daily disability regardless of the exact number of headache days. When choosing a preventive drug, doctors should explain potential side effects and discuss both established options such as propranolol, topiramate and valproate, as well as newer treatments including CGRP-targeting drugs available as pills or injections.
The panel found no single medication works for all patients. The experts suggested that when a patient has no other major health conditions that would exclude certain drugs, the choice should be customized to what matters most to that individual—whether efficacy, side effects or cost. The guidelines note that patients who could become pregnant must be warned about potential risks to a fetus, and medications known to cause birth defects, such as valproate or topiramate, should be avoided.
Preventive medicines require time to demonstrate effectiveness. The guideline recommends giving standard daily medicines at a tolerated dose for at least eight to 12 weeks before concluding they have failed. For Botox treatment, doctors should wait 24 weeks at a tolerated dose before judging the treatment unsuccessful. The panel emphasized that treatment decisions should be tailored to each patient and made in the context of their individual care.