Ann Intern Med

New migraine prevention guideline favors older, established meds

February 5, 2025

The American College of Physicians' new clinical guideline emphasizes the importance of personalized treatment plans and highlights that newer, expensive medications don’t offer significant clinical advantages over established treatments. Clinicians should use an informed decision-making approach and before beginning pharmacological treatment, discuss modifiable factors and triggers, and emphasize hydration, sleep, and physical activity.

Recommendations

• Initiate monotherapy by choosing one of the following: A beta-blocker (either metoprolol or propranolol), the antiseizure medication valproate, the SNRI venlafaxine, or the tricyclic antidepressant amitriptyline (low-certainty evidence).
• In patients who don't tolerate or adequately respond to the aforementioned options, use monotherapy with CGRP antagonists (atogepant or rimegepant) or CGRP monoclonal antibodies (eptinezumab, erenumab, fremanezumab, or galcanezumab) (low-certainty evidence).
• In patients who don't tolerate or adequately respond to the above first- and second-line options, use monotherapy with the antiseizure medication topiramate (low-certainty evidence).

Source:

Qaseem A, et al; Clinical Guidelines Committee of the American College of Physicians. (2025, February 4). Ann Intern Med. Prevention of Episodic Migraine Headache Using Pharmacologic Treatments in Outpatient Settings: A Clinical Guideline From the American College of Physicians. https://pubmed.ncbi.nlm.nih.gov/39899861/