Migraine Prevention

New Migraine Prevention Guidelines - Plain Language Summary

On August 31, 2026, the American Academy of Neurology and the American Headache Society released new guidelines for preventing migraines in adults.

The biggest change is the addition of a newer group of migraine-specific drugs that target a protein called CGRP. CGRP is involved in triggering migraines. These drugs include:

• Pills like atogepant (Qulipta)
• Shots/infusions given monthly or quarterly: eptinezumab (Vyepti), erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emgality)

There is also Botox injections (onabotulinumtoxinA) for people with chronic migraine.

Who should consider prevention?

The guidelines say doctors should tell all migraine patients that prevention options exist. You should be offered a preventive treatment if you have:

• 4 or more migraine days a month, OR
• 4 or more days a month with moderate-to-severe headaches, OR
• Migraines that cause major problems in your daily life

Preventive treatment can mean fewer headache days, less disability, and may help stop occasional migraines from becoming chronic. Right now, fewer people get it than could benefit from it.

There is no single "best" drug

No preventive drug was proven to be clearly better than all the others for everyone. The choice should be made together with your doctor based on what matters most to you:

• If you want the strongest evidence for effectiveness and you don't have other major health issues: For occasional (episodic) migraine, options include the CGRP drugs listed above, plus older drugs propranolol (a blood pressure medicine), topiramate (Topamax), and valproate. For chronic migraine (15+ headache days a month), the list is similar but includes Botox instead of propranolol.

• If you are most worried about side effects: The CGRP drugs and Botox tend to be better tolerated than older drugs.

• If you are worried about long-term or unknown risks: Older drugs with decades of use, like propranolol, topiramate, and Botox, may be preferred.

• Cost and what your insurance covers should also be part of the conversation.

Doctors should also look at your other health conditions. Sometimes one drug can help both. For example, amitriptyline might be suggested if you have both migraine and fibromyalgia, and topiramate might be considered if you also want to avoid weight gain.

Even if you have medication overuse headache (headaches from using pain relievers too often), you should still be offered prevention. CGRP drugs, atogepant, Botox, and topiramate have the best evidence for that situation.

How long do you need to try it?

• For most pills and CGRP shots: try it for 8 to 12 weeks at the right dose before you decide if it works.
• For Botox: it takes longer - 24 weeks (two rounds of shots) before judging.

If it's not helping enough after that time, talk to your doctor about switching to something else.

What about pregnancy?

This was a major focus of the update.

• If you could become pregnant, your doctor should talk to you about any risks to a fetus if you got pregnant unexpectedly.
• Some drugs can cause birth defects and should be avoided if possible when pregnancy is possible: valproate/divalproex sodium and topiramate.
• If you are pregnant or planning to be, the guidelines say to focus on non-drug approaches first: behavioral strategies, acupuncture, exercise, and avoiding triggers.
• If you do need medication during pregnancy, nifedipine (a blood pressure drug) is considered the first choice.
• If that doesn't work, metoprolol or propranolol may be considered after weighing risks and benefits.
• For chronic migraine, Botox may be considered, but there is very little safety data in pregnancy.

If you get migraines, this is a good time to ask your doctor or neurologist if prevention might be right for you, and which option fits your health history, preferences, and budget.

Author

Paddy Kalish OD, JD and B.Arch Author and Blogger