Skip to content

Guidelines

TL;DR — Migraine guidelines broadly agree on clinical diagnosis, early effective acute treatment, limiting repeated acute-drug exposure, individualized prevention and diary-based follow-up; they differ most on first-line prevention, acceptable residual burden and how cost/resource constraints shape sequence. The IHS 2024 global recommendations provide essential and optimal pathways, while its 2025 prevention position advocates absolute on-treatment control goals rather than accepting ≥50% response alone (Puledda 2024, PMID 39133176; Puledda 2024, PMID 39262214; Sacco 2025, PMID 39980456). AHS 2024 permits first-line CGRP-targeted prevention, whereas ACP 2025 issued conditional, low-certainty conventional-first recommendations for nonpregnant adults with episodic migraine (Charles 2024, PMID 38466028; Qaseem 2025, PMID 39899861). Pediatric AAN/AHS guidance remains more cautious because many preventives do not separate from placebo (Oskoui 2019, PMID 31413170). Guidelines are evidence-plus-policy documents: recommendation strength also reflects cost, feasibility, safety and panel judgment.

Core agreement

Domain Cross-guideline consensus
Diagnosis Use ICHD phenotype, examination and secondary-headache red flags
Measurement Headache/migraine days, acute days, disability and patient-valued function
Acute care Treat early with effective route; NSAID/triptan anchors; avoid opioids when possible
Prevention Offer when frequency/disability/acute failure or overuse risk warrants
Selection Match comorbidity, contraindication, reproductive safety and preference
Follow-up Adequate trial, diary response, tolerability/adherence, stop ineffective treatment
MOH Education, acute-use reduction/withdrawal and preventive treatment

European expert consensus compresses this into a ten-step diagnostic/management pathway, endorsed by European Headache Federation and European Academy of Neurology (Eigenbrodt 2021, PMID 34145431).

Major documents

Body/document Year Scope Distinguishing contribution
AAN/AHS episodic prevention 2012 Conventional adult prevention Evidence tiers for repurposed drugs/nutraceuticals (Silberstein 2012, PMID 22529202)
Canadian Headache Society 2012 Episodic prophylaxis Evidence plus practical drug selection (Pringsheim 2012, PMID 22683887)
Italian SISC 2012 Primary-headache diagnosis/treatment Broad pre-CGRP national guidance (Sarchielli 2012, PMID 22581120)
EFNS MOH panel 2011 Medication overuse Withdrawal plus prevention; setting by complexity (Evers 2011, PMID 21834901)
EHF onabotulinumtoxinA 2018 Chronic migraine PREEMPT protocol, response/stopping rules (Bendtsen 2018, PMID 30259200)
AAN/AHS pediatric acute 2019 Children/adolescents Agent/route/age-specific acute evidence (Oskoui 2019, PMID 31413171)
AAN/AHS pediatric preventive 2019 Children/adolescents Shared decision-making under high placebo response (Oskoui 2019, PMID 31413170)
AHS integration consensus 2021 New acute/preventive therapies Practical gepant/ditan/device/CGRP placement (Ailani 2021, PMID 34160823)
French Headache Society 2021/2024 Adult diagnosis and treatment update National diagnostic standard and newer-agent position (Demarquay 2021, PMID 34340812; Moisset 2024, PMID 39406556)
EHF CGRP antibody update 2022 Antibody prevention GRADE-based class guidance and expert statements (Sacco 2022, PMID 35690723)
IHS global acute/preventive 2024 Resource-stratified pharmacology “Essential” and “optimal” pathways (Puledda 2024, PMID 39133176; PMID 39262214)
AHS CGRP position 2024 Prevention access CGRP therapies as first-line option (Charles 2024, PMID 38466028)
SISC/IHS pharmacologic guideline 2025 Full adult pharmacology GRADE recommendations across acute/preventive drugs (Ornello 2025, PMID 40277319)
IHS prevention position 2025 Preventive outcome goals Absolute residual-burden tiers beyond ≥50% response (Sacco 2025, PMID 39980456)
ACP outpatient acute/preventive 2025 Nonpregnant adults with episodic migraine Cost-informed combination acute care and conventional-first conditional prevention (Qaseem 2025, PMID 40096690; PMID 39899861)
IHS non-invasive neuromodulation 2025 Acute and preventive devices Device-specific GRADE recommendations; evidence very low to moderate (Yuan 2025, PMID 41117312)
AHS emergency-department update 2026 Parenteral acute treatment Updated efficacy tiers; discourages IV hydromorphone (Robblee 2026, PMID 41321235)
EHF sex-specific consensus 2026 Sex, fertility, pregnancy and lactation Separates evidence summaries from Delphi consensus where data are sparse (Braca 2026, PMID 41998499)
BASH advanced prevention 2026 UK advanced preventive practice Practical consensus for CGRP therapies and botulinum toxin (Kennedy 2026, PMID 42469019)

Acute-treatment sequencing

IHS global recommendations distinguish what should be feasible in low-resource settings from an optimal full formulary. Core logic is stepped but not rigid: analgesic/NSAID for appropriate attacks, migraine-specific triptan when needed, and gepant/ditan when triptans fail or are unsuitable, with route matched to nausea and attack kinetics (Puledda 2024, PMID 39133176).

Decision Guideline principle Evidence/policy tension
NSAID vs triptan first Severity, prior response and contraindication Cheapest-first may delay effective care
Combine triptan + NSAID Use for partial response/recurrence Adds class-specific harm/exposure
Gepant/ditan placement After failure/unsuitability in many systems Access rule, not evidence they are biologically second-line
Opioids Generally avoid Availability gaps can drive use
Non-oral route Use with vomiting/rapid attacks Device/formulation cost and availability

Real-world app analysis of 10.8 million attack records found triptans among the highest self-reported effectiveness classes, broadly aligning with network evidence but subject to user selection and self-report (Chiang 2023, PMID 38030397).

ACP 2025 recommends adding a triptan to an NSAID after inadequate NSAID response (strong, moderate-certainty) and conditionally adding a triptan to acetaminophen after inadequate acetaminophen response in nonpregnant adults with episodic migraine (Qaseem 2025, PMID 40096690). Its population and economic framework are narrower than IHS global guidance and should not be generalized to chronic migraine, pregnancy or every health system.

Preventive thresholds and trial duration

Guidelines do not support waiting for chronic migraine before prevention. Frequency, disability, prolonged attacks, contraindicated/ineffective acute therapy, patient preference and MOH risk can each justify it.

Preventive type Typical assessment window Response framing
Oral drug Titration plus ≥8–12 weeks at tolerated target MMD reduction, function and harms
CGRP antibody Usually 3 months; some delayed responders ≥50% episodic or ≥30% chronic plus disability
OnabotulinumtoxinA At least 2–3 cycles in many guidance pathways Headache-day reduction and functional benefit
Preventive gepant 12-week trial evidence; ongoing review MMD, adherence, interactions and harms

The EHF onabotulinumtoxinA statement recommends PREEMPT dosing and defines nonresponse commonly as <30% headache-day reduction, while allowing disability/intensity to influence continuation (Bendtsen 2018, PMID 30259200).

The IHS 2025 position argues that relative response can conceal substantial residual disability and proposes on-treatment tiers: migraine freedom, optimal control (<4 migraine or moderate/severe headache days/month), modest control (4–6) and insufficient control (>6). It is a real-world aspirational position rather than a new clinical-trial endpoint standard (Sacco 2025, PMID 39980456).

The CGRP first-line disagreement

The disagreement has moved over time:

  1. early documents positioned antibodies after failure of established preventives because long-term data and cost were uncertain;
  2. EHF 2022 suggested CGRP antibodies as a first-line treatment option while acknowledging access and evidence gaps (Sacco 2022, PMID 35690723);
  3. AHS 2024 explicitly stated CGRP-targeted therapies should be considered first-line without requiring prior failure (Charles 2024, PMID 38466028).
Argument for first-line option Counterweight
Migraine-specific mechanism and high-certainty efficacy Average active–placebo difference remains modest
Lower discontinuation than many oral drugs Acquisition cost and payer budget impact
Avoids months of predictable intolerance Long-term pregnancy/rare-event evidence still developing
Reduces inequitable step-therapy delay Unrestricted access may crowd out lower-cost responders

This is a sequencing and access disagreement, not a dispute that the agents work.

ACP 2025 adds a sharper policy contrast: all three episodic-prevention recommendations were conditional and based on low-certainty evidence, with initial monotherapy choices shaped by comparative benefit, harm and cost (Qaseem 2025, PMID 39899861). BASH 2026, by contrast, focuses on practical use of advanced CGRP and botulinum-toxin treatments within the UK and explicitly identifies access inconsistency (Kennedy 2026, PMID 42469019).

Conventional prevention

The 2012 AAN/AHS guideline categorized divalproex/valproate, topiramate, metoprolol, propranolol and timolol as established effective for episodic prevention, with candesartan and several others at lower evidence tiers; a contemporaneous comparison found methodological and recommendation differences across society guidelines (Silberstein 2012, PMID 22529202; Loder 2012, PMID 22671714). Canadian guidance similarly prioritized efficacy, comorbidity and adverse effects (Pringsheim 2012, PMID 22683887).

Older classifications predate current reproductive restrictions, CGRP therapies and newer comparative meta-analysis. “Level A” means evidence under that guideline’s framework, not first choice for every patient.

Nutraceutical recommendations differ because trials are small and formulations vary. A cross-guideline review found conflicting positions on magnesium, riboflavin, coenzyme Q10 and butterbur; safety/quality issues make “natural” an inadequate category (Rajapakse 2016, PMID 26954394).

Medication-overuse headache

EFNS guidance recommended education, withdrawal—abrupt or tapered by class—and preventive therapy, with inpatient management for opioid/barbiturate/benzodiazepine overuse or substantial comorbidity (Evers 2011, PMID 21834901). New CGRP data allow prevention-first or concurrent strategies, but do not nullify hazardous withdrawal.

Modern primer evidence supports a flexible combined approach rather than insisting detoxification precede all prevention (Ashina 2023, PMID 36732518).

Pediatrics

The acute pediatric guideline supports ibuprofen, acetaminophen and selected triptan formulations, emphasizing early treatment, route and overuse counselling (Oskoui 2019, PMID 31413171). The preventive guideline finds insufficient evidence for many drugs, incorporates CBT and requires discussion of high placebo response/adverse effects (Oskoui 2019, PMID 31413170).

Adult first-line CGRP statements cannot be silently applied to children; age-specific trials and long-term developmental safety remain necessary.

The 2026 EHF sex-specific consensus is current but illustrates evidence–consensus separation: only 37 studies informed 10 evidence summaries across 24 questions, and Delphi consensus filled many reproductive gaps (Braca 2026, PMID 41998499). Its pregnancy and lactation statements should therefore be read with the underlying evidence grade and agent-specific exposure data, not as uniform class proof.

Imaging and diagnostic testing

AHS guidance states routine neuroimaging is unnecessary for migraine-consistent headache, normal neurological examination and no red flags. Imaging may be considered for unusual/prolonged aura, change in frequency/features, first/worst event, brainstem or motor aura, side-locked or post-traumatic headache; much of the “may consider” list is consensus (Evans 2020, PMID 31891197).

Guidelines should not be used as rules that override a new abnormal examination or time-critical secondary-headache phenotype.

Neuromodulation

The 2013 EHF position reserved invasive neuromodulation for medically intractable chronic headache after excluding MOH and exhausting conservative treatment (Martelletti 2013, PMID 24144382). IHS 2025 now provides the current non-invasive device guidance: 15 eligible studies yielded weak recommendations for selected acute and preventive devices, with evidence ranging from very low to moderate and explicit concern about imprecision, sham integrity and adherence (Yuan 2025, PMID 41117312). The older EHF document therefore remains most relevant to implants rather than all neuromodulation.

Emergency-department care

The AHS 2025 evidence update, published in 2026, reviewed 26 new RCTs. It rated IV prochlorperazine and greater-occipital nerve block as “must offer” when eligible, several parenteral options as “should offer,” and IV hydromorphone as “must not offer”; eptinezumab's recommendation was limited to the trial-matched population rather than an ED-specific population (Robblee 2026, PMID 41321235). These recommendations address parenteral ED care and do not replace outpatient acute sequencing.

Resource and implementation gap

IHS “essential” pathways acknowledge that the best-supported or best-tolerated agent may be unavailable. African consensus recommendations similarly adapt care to medicine and specialist availability (Ahmed 2016, PMID 27642420).

Norwegian GP survey found knowledge gaps in diagnosis and management despite a well-resourced system, demonstrating that publication does not equal implementation (Kristoffersen 2021, PMID 34763647).

Implementation barrier Potential control
Complex criteria Short diagnostic algorithm plus red flags
No diary/follow-up Standard 4-week baseline and response template
Payer step therapy Record adequate failures/contraindications transparently
Specialist scarcity Primary-care essential pathway and escalation criteria
Medicine scarcity Route/class alternatives rather than no plan
Reproductive risk Standard pregnancy-potential review before preventive

Methodological caution

Guidelines differ in search dates, GRADE versus older evidence levels, panel composition, conflict management and whether cost is explicit. Acute-trial endpoints themselves vary, so guideline comparisons may be comparing different outcomes (García-Azorin 2018, PMID 30242571).

Superseded guidance remains historically useful but should not be quoted as current without checking newer versions. The registry records these chains.

Open questions

  • Does first-line CGRP access improve long-term function and cost versus structured conventional step care? (Charles 2024, PMID 38466028)
  • Can guideline developers harmonize response, adequate-trial and refractory definitions across regions? (Ornello 2025, PMID 40277319)
  • Which essential-package intervention reduces the largest population disability in low-resource settings? (Puledda 2024, PMID 39133176)
  • How should pregnancy and pediatric evidence gaps be represented without converting uncertainty into blanket denial? (Oskoui 2019, PMID 31413170)
  • Which implementation tool changes GP diagnosis/treatment behaviour rather than knowledge scores alone? (Kristoffersen 2021, PMID 34763647)

References

  1. Puledda F, et al. IHS global practice recommendations for acute pharmacological treatment. Cephalalgia. 2024. PMID 39133176
  2. Puledda F, et al. IHS global practice recommendations for preventive pharmacological treatment. Cephalalgia. 2024. PMID 39262214
  3. Ailani J, et al. AHS consensus statement on integrating new migraine treatments. Headache. 2021. PMID 34160823
  4. Charles AC, et al. CGRP-targeting therapies as a first-line prevention option: AHS update. Headache. 2024. PMID 38466028
  5. Sacco S, et al. EHF guideline on CGRP monoclonal antibodies: 2022 update. J Headache Pain. 2022. PMID 35690723
  6. Ornello R, et al. Evidence-based guidelines for pharmacological treatment of migraine. Cephalalgia. 2025. PMID 40277319
  7. Eigenbrodt AK, et al. Diagnosis and management of migraine in ten steps. Nat Rev Neurol. 2021. PMID 34145431
  8. Silberstein SD, et al. AAN/AHS guideline: episodic migraine prevention in adults. Neurology. 2012. PMID 22529202
  9. Loder E, et al. 2012 AHS/AAN prevention guidelines: comparison with other guidelines. Headache. 2012. PMID 22671714
  10. Pringsheim T, et al. Canadian Headache Society guideline for migraine prophylaxis. Can J Neurol Sci. 2012. PMID 22683887
  11. Sarchielli P, et al. Italian guidelines for primary headaches: 2012 revision. J Headache Pain. 2012. PMID 22581120
  12. Demarquay G, et al. French Headache Society adult migraine guideline, part 1. Rev Neurol (Paris). 2021. PMID 34340812
  13. Moisset X, et al. Migraine treatment: French Headache Society position paper. Rev Neurol (Paris). 2024. PMID 39406556
  14. Bendtsen L, et al. EHF onabotulinumtoxinA guideline for chronic migraine. J Headache Pain. 2018. PMID 30259200
  15. Evers S, Jensen R. EFNS guideline on treatment of MOH. Eur J Neurol. 2011. PMID 21834901
  16. Oskoui M, et al. Pediatric acute migraine guideline update. Neurology. 2019. PMID 31413171
  17. Oskoui M, et al. Pediatric preventive migraine guideline update. Neurology. 2019. PMID 31413170
  18. Evans RW, et al. Neuroimaging for migraine: AHS guideline. Headache. 2020. PMID 31891197
  19. Martelletti P, et al. Neuromodulation of chronic headaches: EHF position statement. J Headache Pain. 2013. PMID 24144382
  20. Ahmed MA, et al. Practice recommendations for migraine in African adults. Pan Afr Med J. 2016. PMID 27642420
  21. Kristoffersen ES, et al. Headache knowledge among Norwegian GPs. J Headache Pain. 2021. PMID 34763647
  22. Chiang CC, et al. Comparisons of 25 acute medicines from 10 million app records. Neurology. 2023. PMID 38030397
  23. Rajapakse T, Pringsheim T. Nutraceuticals in migraine: summary of guidelines. Headache. 2016. PMID 26954394
  24. García-Azorin D, et al. Endpoints in symptomatic primary-headache trials: systematic review. J Headache Pain. 2018. PMID 30242571
  25. Ashina S, et al. Medication overuse headache. Nat Rev Dis Primers. 2023. PMID 36732518
  26. Sacco S, et al. Setting higher standards for migraine prevention: IHS position statement. Cephalalgia. 2025. PMID 39980456
  27. Qaseem A, et al. Pharmacologic treatments of acute episodic migraine in outpatient settings: ACP guideline. Ann Intern Med. 2025. PMID 40096690
  28. Qaseem A, et al. Prevention of episodic migraine using pharmacologic treatments in outpatient settings: ACP guideline. Ann Intern Med. 2025. PMID 39899861
  29. Yuan H, et al. IHS evidence-based guidelines on non-invasive neuromodulation devices for migraine. Cephalalgia. 2025. PMID 41117312
  30. Robblee J, et al. AHS guideline update to acute migraine treatment in the emergency department. Headache. 2026. PMID 41321235
  31. Braca S, et al. Sex-specific management of migraine: EHF systematic review and consensus statement. J Headache Pain. 2026. PMID 41998499
  32. Kennedy A, et al. BASH clinical practice recommendations for advanced migraine preventives. J Neurol Neurosurg Psychiatry. 2026. PMID 42469019