Migraine

Updated February 12, 2025

What's new

The American College of Physicians (ACP) has released a new guideline on pharmacological prophylaxis for episodic migraine in nonpregnant adults in outpatient settings. First-line options include monotherapy with a beta-blocker (metoprolol or propranolol), valproate, venlafaxine, and amitriptyline. Second-line options include topiramate, CGRP antagonists (atogepant or rimegepant), and CGRP antibodies (eptinezumab, erenumab, fremanezumab, or galcanezumab). .

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.

Pathophysiology

Migraine is due to complex brain network disorder involving the cortex, hypothalamus, thalamus, and brainstem in genetically predisposed individuals.

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%.

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.

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.

Guidelines

Key sources

The following summarized guidelines for the management of migraine are prepared by our editorial team based on guidelines from the American College of Physicians (ACP 2025), the American Academy of Family Physicians (AAFP 2024), 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 ...