Guideline registry — migraine¶
Last audited: 2026-08-30. This registry separates recommendation documents from trials and reviews. Every PMID was re-fetched through live PubMed E-utilities in the audit session, and a 2025–2026 currency search added seven documents. Recommendations age quickly; confirm the current local label, formulary and pregnancy guidance before clinical use.
Master table¶
| Body / region | Year | Scope | Load-bearing position | PMID | Status note |
|---|---|---|---|---|---|
| International Headache Society | 2024 | Acute pharmacological care, global | Stepwise selection by efficacy, safety, access and patient context | 39133176 | Current global practice recommendation |
| International Headache Society | 2024 | Preventive pharmacological care, global | Individualized initiation, monitoring and stopping | 39262214 | Current global practice recommendation |
| American Headache Society | 2021 | New acute/preventive treatments, US | Integration of gepants, ditan, CGRP antibodies and devices | 34160823 | Partly superseded for CGRP placement |
| American Headache Society | 2024 | CGRP-targeted prevention, US | CGRP therapies may be first-line without mandatory prior failures | 38466028 | Current position update |
| European Headache Federation | 2022 | CGRP monoclonal antibodies, Europe | Recommends class with response evaluation and individualized continuation | 35690723 | Current EHF class update |
| European Headache Federation | 2018 | OnabotulinumtoxinA, Europe | PREEMPT protocol; response/stopping framework | 30259200 | Still operational; watch for update |
| European Federation of Neurological Societies | 2011 | Medication-overuse headache, Europe | Education/withdrawal and prevention; drug-specific withdrawal care | 21834901 | Old; interpret with newer evidence |
| AAN/AHS | 2012 | Episodic prevention, US | Evidence tiers for conventional oral preventives | 22529202 | Historical baseline; predates CGRP era |
| Canadian Headache Society | 2012 | Prevention, Canada | Evidence and consensus recommendations for available agents | 22683887 | Predates CGRP era |
| Italian Society for the Study of Headaches | 2012 | Primary headache treatment, Italy | Acute and preventive pharmacological recommendations | 22581120 | Predates current targeted therapies |
| French Headache Society | 2021 | Adult diagnosis and management, France | Structured diagnosis, assessment and treatment pathway | 34340812 | Current framework |
| French Headache Society | 2024 | Treatment position, France | Updates acute/preventive placement in national context | 39406556 | Current national update |
| AAN/AHS | 2019 | Pediatric acute treatment, US | Ibuprofen/acetaminophen and selected triptans; formulation matters | 31413171 | Current evidence update |
| AAN/AHS | 2019 | Pediatric prevention, US | Shared decision-making; limited drug superiority and high placebo response | 31413170 | Current evidence update |
| American Headache Society | 2020 | Neuroimaging | No routine imaging for stable typical migraine with normal examination | 31891197 | Current evidence-based guidance |
| European Headache Federation | 2013 | Neuromodulation | Device-specific appraisal; evidence then immature | 24144382 | Historical; many devices emerged later |
| African expert group | 2016 | Adult migraine practice in Africa | Resource-sensitive recognition and treatment | 27642420 | Important regional lens; update needed |
| European/International expert group | 2021 | Ten-step diagnosis and management | Practical care algorithm across diagnosis, acute and preventive care | 34145431 | Consensus review, not formal GRADE guideline |
| International methods group | 2018 | Symptomatic headache trial endpoints | Exposes endpoint inconsistency across acute trials | 30242571 | Methods reference |
| Review of guidelines | 2016 | Nutraceuticals | Recommendations differ because evidence and grading differ | 26954394 | Comparison, not a guideline |
| International Headache Society | 2025 | Preventive outcome standards, global | Adds absolute residual-burden tiers to relative response | 39980456 | Current position statement |
| American College of Physicians | 2025 | Acute episodic migraine, US outpatient | Cost-informed triptan-plus-analgesic recommendations | 40096690 | Current; nonpregnant adults with episodic migraine |
| American College of Physicians | 2025 | Episodic prevention, US outpatient | Conditional, low-certainty conventional-first monotherapy sequence | 39899861 | Current; narrower than AHS first-line CGRP position |
| International Headache Society | 2025 | Non-invasive neuromodulation, global | Device-specific GRADE recommendations; evidence very low to moderate | 41117312 | Current device guideline; supersedes 2013 document for non-invasive devices |
| American Headache Society | 2025 update, published 2026 | Parenteral emergency-department acute treatment, US | Updated efficacy tiers; IV hydromorphone “must not offer” | 41321235 | Current ED evidence update |
| European Headache Federation | 2026 | Sex-specific and reproductive management, Europe | Systematic review plus Delphi consensus across sex, fertility, pregnancy and lactation | 41998499 | Current; distinguish evidence from consensus |
| British Association for the Study of Headache | 2026 | Advanced prevention, UK | Practical CGRP and botulinum-toxin access/use consensus | 42469019 | Current UK consensus guidance |
Recommendation map¶
| Decision | Broad agreement | Material disagreement / dependency |
|---|---|---|
| Diagnose clinically | Use ICHD phenotype and exclude a better cause | Primary-care tools and specialist access differ |
| Routine imaging | Avoid in stable typical migraine with normal examination | Lower threshold for atypical aura, pattern change and red flags |
| Acute first choices | NSAID or triptan when appropriate | Formularies, cardiovascular context and prior response alter sequence |
| Gepants / lasmiditan | Options after ineffective, poorly tolerated or unsuitable triptan | Some systems require step therapy; comparative cost-effectiveness varies |
| Start prevention | Base on disability, frequency, acute-treatment failure and preference | No universal monthly-day threshold |
| CGRP first-line status | AHS 2024 permits first-line use | Payer and national rules may still require conventional failures |
| OnabotulinumtoxinA | Evidence-based for chronic migraine using PREEMPT protocol | Not established for episodic migraine; stopping rules vary |
| MOH | Educate, address overused exposure and offer effective prevention | Abrupt vs gradual withdrawal and timing of prevention depend on drug/person |
| Pediatric prevention | Emphasize shared decisions and behavioural care | Few medicines consistently beat placebo |
| Pregnancy/lactation | Drug-specific risk–benefit review | Evidence for newer CGRP agents is sparse and evolves through registries |
| Preventive success | Measure residual MMD/disability, not percentage alone | IHS 2025 proposes absolute control tiers; reimbursement often uses relative thresholds |
| Non-invasive devices | Weak recommendations for selected cleared devices | Evidence ranges from very low to moderate; sham, adherence and access remain limiting |
| ED parenteral treatment | Use evidence-ranked antiemetics/NSAIDs/triptan or nerve blocks when appropriate | Recommendations differ by eligibility, contraindication and trial-matched population |
Selected guideline entries¶
IHS global acute recommendations (2024)¶
PMID 39133176. A globally oriented treatment framework that makes diagnosis, attack characteristics, prior response, contraindications, availability and affordability part of drug choice. It supports migraine-specific escalation without assuming every health system can follow one formulary sequence.
IHS global preventive recommendations (2024)¶
PMID 39262214. Frames prevention around burden and shared decision-making, with explicit monitoring of frequency, disability, harms and patient goals. It is the best current cross-system anchor but does not erase local label or pregnancy constraints.
AHS integration consensus (2021) → AHS CGRP update (2024)¶
PMIDs: 34160823 and 38466028. The 2021 document placed new acute drugs, devices and CGRP prevention within existing practice. The 2024 update materially changed placement by supporting CGRP-targeted therapies as a first-line prevention option without mandatory failure of older classes.
EHF CGRP antibody guideline (2022)¶
PMID 35690723. Evaluates antibody efficacy and safety, response assessment and duration questions. Its clinical recommendation may be more permissive than reimbursement rules in individual European systems.
EHF onabotulinumtoxinA guideline (2018)¶
PMID 30259200. Ties treatment to the PREEMPT injection protocol and commonly defines nonresponse as less than 30% headache-day reduction, while allowing intensity, disability and preference to affect continuation.
AAN/AHS conventional prevention guideline (2012)¶
PMID 22529202. A foundational evidence grading of conventional oral preventives. It remains useful for the evidence history but predates CGRP antibodies/gepants and should not be used alone to infer current class order.
Paediatric acute and preventive updates (2019)¶
PMIDs: 31413171 and 31413170. Acute guidance supports selected analgesics and triptan formulations with age- and route-specific evidence. Preventive guidance emphasizes the limited superiority over placebo, harms and shared decisions rather than importing adult hierarchies.
AHS neuroimaging guideline (2020)¶
PMID 31891197. Routine neuroimaging is not necessary for stable migraine meeting clinical criteria with a normal neurological examination. The document lists situations where imaging may be considered; red-flag assessment remains upstream of the “no routine imaging” conclusion.
EFNS medication-overuse guideline (2011)¶
PMID 21834901. Establishes education, withdrawal and prevention as the treatment frame. It predates CGRP-era evidence and newer strategy trials, so drug-specific dependence and contemporary prevention data must supplement it.
African practice recommendations (2016)¶
PMID 27642420. Important because availability, affordability and specialist scarcity materially change a usable algorithm. Its age and limited regional evidence base make an updated resource-stratified African process a priority.
IHS higher prevention standards (2025)¶
PMID 39980456. Proposes absolute on-treatment tiers—migraine freedom, optimal control (<4 migraine or moderate/severe headache days/month), modest control (4–6) and insufficient control (>6)—to expose residual burden hidden by a ≥50% response. It is aimed at real-world clinical goals rather than changing registration-trial endpoint standards.
ACP outpatient acute and preventive guidelines (2025)¶
PMIDs: 40096690 and 39899861. The acute guideline recommends adding a triptan to an NSAID after inadequate NSAID response and conditionally adding one to acetaminophen after inadequate acetaminophen response. The preventive guideline makes three conditional, low-certainty recommendations for initial and subsequent monotherapy in nonpregnant adults with episodic migraine. Its cost-sensitive conventional-first sequence materially differs from AHS 2024 first-line CGRP placement.
IHS non-invasive neuromodulation guideline (2025)¶
PMID 41117312. Fifteen eligible studies supported weak recommendations for selected acute and preventive devices; certainty ranged from very low to moderate. It makes the 2013 EHF document historical for non-invasive devices while leaving that older document relevant to invasive neuromodulation.
AHS emergency-department update (2025/2026)¶
PMID 41321235. Updates parenteral ED evidence through February 2025. IV prochlorperazine and greater-occipital nerve block received “must offer” recommendations for eligible adults, while IV hydromorphone received “must not offer”; eptinezumab was limited to trial-matched rather than ED-specific evidence.
EHF sex-specific consensus (2026)¶
PMID 41998499. A systematic review plus Delphi process addressed 24 questions, but only 37 studies informed 10 evidence summaries. It is a current reproductive-management source whose consensus statements should not be mistaken for uniform high-certainty comparative safety evidence.
BASH advanced preventive guidance (2026)¶
PMID 42469019. UK consensus guidance addresses practical use and access for CGRP-targeted treatments and botulinum toxin. It is a selective-search, modified-Delphi document rather than a de novo GRADE guideline.
Supersession chains¶
- US prevention: AAN/AHS 2012 (PMID 22529202) → AHS integration consensus 2021 (PMID 34160823) → AHS CGRP first-line update 2024 (PMID 38466028).
- European CGRP antibodies: early access rules → EHF 2022 update (PMID 35690723); local reimbursement rules may lag the evidence statement.
- French practice: 2021 diagnostic/management framework (PMID 34340812) → 2024 treatment position (PMID 39406556).
- Pediatric US: acute and preventive evidence were updated as paired 2019 guidelines (PMIDs: 31413171, 31413170).
- Non-invasive neuromodulation: EHF 2013 (PMID 24144382) → IHS evidence-based device guideline 2025 (PMID 41117312); retain the EHF document for invasive-device history.
- US outpatient pharmacology: older AAN/AHS evidence tiers and AHS CGRP position remain relevant, but ACP 2025 (PMIDs: 40096690, 39899861) adds a distinct cost-informed outpatient sequence rather than superseding society guidance.
- US emergency care: earlier AHS parenteral evidence assessment → 2025 update published 2026 (PMID 41321235).
Gaps and watch list¶
- Head-to-head sequencing among conventional preventives, CGRP antibodies, preventive gepants and onabotulinumtoxinA.
- Clear combination-therapy criteria and stopping/rechallenge rules.
- Guidance based on pregnancy exposure registries for gepants and CGRP antibodies.
- Updated African, Latin American and other resource-stratified recommendations; 2025–2026 searches found new Asian consensus documents, but this registry retains only documents whose method and scope were audited here.
- Post-market comparative data and stronger sham-controlled trials to upgrade the weak 2025 IHS device recommendations.
- Formal incorporation of interictal, cognitive and family burden into treatment success.
Implementation cautions¶
- A society recommendation is not a local authorization, label or reimbursement decision.
- “First line” describes clinical placement, not guaranteed access or superiority for an individual.
- Consensus statements can be useful where randomized evidence is impossible, but evidence certainty and expert recommendation must remain distinct.
- A document’s publication year is not proof it remains active; future updates should record explicit replacement.