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Migraine

What's new

The American College of Physicians (ACP) has released new guidelines on pharmacological prophylaxis and management of episodic migraine in nonpregnant adults in outpatient settings. First-line options for prophylaxis include monotherapy with a beta-blocker (metoprolol or propranolol), valproate, venlafaxine, and amitriptyline. Second-line options for prophylaxis include topiramate, CGRP antagonists (atogepant or rimegepant), and CGRP antibodies (eptinezumab, erenumab, fremanezumab, or galcanezumab). For the treatment of moderate-to-severe acute episodic migraine, triptans are recommended in addition to NSAIDs in patients not responding adequately to NSAIDs alone. .

Background

Overview

Definition
Migraine is a primary headache disorder characterized by recurrent moderate-to-severe headaches, often accompanied by nausea, vomiting, and/or sensitivity to light and sound.
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Pathophysiology
Migraine is due to complex brain network disorder involving the cortex, hypothalamus, thalamus, and brainstem in genetically predisposed individuals.
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Epidemiology
The overall prevalence of migraine over a 3-month period in the US adult population is 15.3%, affecting approximately 20.7% of females and 9.7% of males. The global lifetime prevalence of migraines is estimated at 14%.
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Disease course
The complex interplay between cortex, hypothalamus, thalamus, brainstem involved in modulation of nociceptive signaling results in trigeminovascular system activation, cortical-spreading depression-like event, a slowly propagating wave of neuronal and glial cell depolarization and hyperpolarization causing unilateral, pulsating, moderate to severe intensity headache with or without aura.
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Prognosis and risk of recurrence
Acute migraine therapies (triptans, ergotamines, NSAIDs) are ineffective and account for > 50% recurrence of migraine. Approximately 2.2-3.1% of people with episodic migraine progress to chronic migraine at 1-year follow up.
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Guidelines

Key sources

The following summarized guidelines for the management of migraine are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2025,2024), the American College of Physicians (ACP 2025), the United States Department of Defense (DoD/VA 2024), the Canadian Expert Group on Cannabinoids Use in Chronic Pain (CCP-CEG 2023), the The Scottish Intercollegiate Guidelines Network ...
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Medical management

Management of acute attacks, analgesics
As per AAFP 2025 guidelines:
Offer NSAIDs as first-line treatment for mild-to-moderate migraine.
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Avoid opioids or butalbital-containing medications for the treatment of migraine, except in refractory cases.
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  • Management of acute attacks (triptans)

  • Management of acute attacks (cannabinoids)

  • Management of acute attacks (antiemetics)

  • Management of acute attacks (gepants)

  • Management of acute attacks (ditans)

  • Management of acute attacks (other agents)

  • Management of acute attacks (addressing medication overuse)

Nonpharmacologic interventions

Physical therapy: as per AAFP 2025 guidelines, consider offering exercise as an option for migraine prevention.
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  • Behavioral interventions

  • Dietary modifications

  • Alternative and complementary therapies

Therapeutic procedures

Botulinum toxin injection: as per AAFP 2025 guidelines, offer onabotulinumtoxinA injection for chronic migraine prophylaxis.
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  • Greater occipital nerve block

  • Supraorbital nerve block

  • Sphenopalatine ganglion block

  • Cervical nerve pulsed radiofrequency

  • Neuromodulation

Surgical interventions

Patent foramen ovale closure: as per DoD/VA 2024 guidelines, avoid offering patent foramen ovale closure for the treatment or prevention of migraine.
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Specific circumstances

Patients with menstrual migraine: as per SIGN 2023 guidelines, offer triptans in patients with acute migraine associated with menstruation.
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  • Pediatric and adolescent patients (diagnosis)

  • Pediatric and adolescent patients (screening for comorbidities)

  • Pediatric and adolescent patients (counseling on prevention)

  • Pediatric and adolescent patients (pharmacologic prophylaxis)

  • Pediatric and adolescent patients (counseling on acute treatment)

  • Pediatric and adolescent patients (management of acute attacks)

  • Pediatric and adolescent patients (monitoring)

Preventative measures

Migraine prophylaxis, general principles
As per ACP 2025 guidelines:
Consider initiating monotherapy with a β-blocker (metoprolol or propranolol), valproate, venlafaxine, or amitriptyline for the prevention of episodic migraine in nonpregnant adults in outpatient settings.
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Use an informed decision-making approach and discuss benefits, harms, costs, patient's values, and preferences, including financial burden and mode of administration, contraindications, pregnancy and reproductive status in females, clinical comorbidities, and availability when selecting a pharmacologic treatment for the prevention of episodic migraine.
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  • Migraine prophylaxis (beta-blockers)

  • Migraine prophylaxis (anticonvulsants)

  • Migraine prophylaxis (ACEis/ARBs)

  • Migraine prophylaxis (CGRP inhibitors)

  • Migraine prophylaxis (antidepressants)

  • Migraine prophylaxis (NSAIDs)

  • Migraine prophylaxis (CCBs)

  • Migraine prophylaxis (alpha-agonists)

  • Migraine prophylaxis (ergolines)

  • Migraine prophylaxis (other agents)

  • Migraine prophylaxis (dietary and herbal supplements)