Migraine Headache Guidelines: US Headache Consortium, American Headache Society

The American Academy of Neurology and the American Headache Society collaboratively released guidelines on the pharmacologic treatment for episodic migraine prevention in adults.

Migraine is a common, disabling, and costly disorder. There is no cure, but preventive treatment to decrease the number and severity of headache attacks improves health outcomes and quality of life.3 It also reduces disability and costs.

The initial selection of agents should be based on the level of established efficacy. Routinely evaluate patient response and utilize factors such as comorbidities, personal considerations, and adverse reactions to guide and individualize therapy. Comparisons of efficacy amongst agents of the same drug class for short-term as well as chronic use have not been established by the evidence currently available.

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Frequent or high dosing of these medications can lead to rebound headaches and progression to chronic headache disorders. Initiate at the lowest possible dose then increase to desired effect or development of an adverse reaction. An adequate trial length is between 2−6months. Discontinuation via a taper is encouraged if a patient is well-controlled after 6−12months of therapy.

According to the guidelines, the following medications are established as effective and should be offered for migraine prevention (level A recommendation):

• Antiepileptic drugs (AEDs): divalproex sodium, sodium valproate, topiramate


• β-Blockers: metoprolol, propranolol, timolol


• Triptans: frovatriptan for short-term MAMs prevention

The following medications are probably effective and should be considered for migraine prevention (level B recommendation):

• Antidepressants: amitriptyline, venlafaxine


• β-Blockers: atenolol, nadolol


• Triptans: naratriptan, zolmitriptan for short-term MAMs prevention

The following medications are possibly effective and may be considered for migraine prevention (level C recommendation):

• ACE inhibitors: lisinopril


• Angiotensin receptor blockers: candesartan


• α-Agonists: clonidine, guanfacine


• AEDs: carbamazepine


• β-Blockers: nebivolol, pindolol

NSAIDs and other complementary treatments for episodic migraine prevention in adults

The American Academy of Neurology and the American Headache Society also released guidelines regarding the use of NSAIDs and complementary treatments in preventing episodic migraine.

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The following therapy is established as effective and should be offered for migraine prevention (level A recommendation):

• Petasites (butterbur)

The following therapies are probably effective and should be considered for migraine prevention (level B recommendation):

• NSAIDS: fenoprofen, ibuprofen, ketoprofen, naproxen, naproxen sodium


• Herbal therapies, vitamins, and minerals: riboflavin, magnesium, MIG-99 (feverfew)


• Histamines: histamine SC

The following therapies are possibly effective and may be considered for migraine prevention (level C recommendation):

• NSAIDs: flurbiprofen, mefenamic acid


• Herbal therapies, vitamins, and minerals: Co-Q10, estrogen


• Antihistamines: cyproheptadine