New AAN and AHS Guidelines Expand Pharmacological Options for Migraine Prevention
核心洞察
The American Academy of Neurology (搜索) and American Headache Society (搜索) released updated migraine (搜索) prevention guidelines, their first since 2012, based on a systematic review of 217 studies published through June 6, 2024.
The guidelines recommend offering preventive treatment to adults with four or more migraine (搜索) or severe headache days per month, or whose migraines interfere with work or daily tasks.
High-confidence evidence supports CGRP-targeted therapies such as galcanezumab, erenumab, fremanezumab, and eptinezumab, alongside older options like onabotulinumtoxinA, propranolol, and topiramate.
New guidelines from the American Academy of Neurology (搜索) (AAN) and the American Headache Society (搜索) (AHS) aim to help clinicians provide preventive treatment and medication to adults with migraine (搜索) more effectively, marking the first update to these recommendations since 2012.
The updated guidelines incorporate new developments in research that have emerged over the past decade, according to guideline author Rebecca C. Burch, MD, a neurologist and headache medicine specialist with the University of Vermont Medical Center. "Since the previous guidelines were published in 2012, there has been a wealth of new treatments available for prevention of migraine (搜索), and specifically the migraine-specific [calcitonin gene-related peptide] targeted therapy category," Burch said during a press conference.
Evidence Base and Panel Composition
The guidelines were produced by a multidisciplinary panel, convened in January 2018, that conducted a systematic review of 217 studies published through June 6, 2024, according to the recommendations published in Neurology. In addition to AAN staff and an AHS representative, the panel included content experts, methodologists, patient representatives, and advocates.
The group tasked with writing the new recommendations included 19 headache specialists and researchers from around the U.S., plus several experts from Canada. About one-third of the panel had relevant conflicts of interest and were therefore not allowed to rate or review evidence, though they voted along with the rest of the group on the recommendations. Conflict-free authors led the development of the guidelines.
Who Should Receive Preventive Treatment
The guidelines recommend that clinicians offer preventive treatments to people who experience four or more migraine (搜索) days per month, or four or more moderate to severe headache days per month. Preventive treatments should also be offered to patients for whom migraine is affecting their ability to work or perform daily tasks.
An estimated 15% of Americans experience migraines, with women disproportionately affected. Many try to manage their pain with over-the-counter options once an attack has begun. Preventive options can reduce the frequency of headache days, but many patients do not know they qualify for those treatments. "We know from studies of the U.S. population that many more patients with migraine (搜索) are eligible," Burch said in a news conference.
Recommended Therapies by Migraine Type
The recommendations cover both chronic and episodic migraine (搜索). Chronic migraine is defined as headache on 15 or more days per month for over three months, with at least eight of those headache days including migraine features such as severe pain lasting for hours or days, nausea, aura, light sensitivity, or discomfort with loud sounds.
For episodic migraine (搜索), the panel found high-confidence evidence showing that galcanezumab and erenumab are more effective than placebo in reducing headache frequency. For chronic migraine, the panel found high-confidence evidence of reductions in headache frequency with fremanezumab, galcanezumab, and onabotulinumtoxinA.
Newer therapies targeting the calcitonin gene-related peptide (CGRP) pathway—including atogepant (Qulipta), eptinezumab (Vyepti), erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emgality)—received high marks for their efficacy and tolerability. These medications were also recommended as a preventive option for patients who frequently rely on pain medication once their attacks begin, as some people experience a reduction in headache frequency once they taper down their acute pain medications.
The guidelines also highlight older treatments with more long-term safety data, including Botox (onabotulinumtoxinA) for chronic migraine (搜索), propranolol for episodic migraines, and the anti-seizure drug topiramate. Botox is well tolerated among migraine patients, according to studies the authors reviewed.
Patient-Specific Considerations
The guidelines touch on specific situations, including treating patients with fibromyalgia, obesity, and hypertension, older patients, pregnant patients, and patients with medication overuse. They also help clinicians consider factors such as efficacy, adverse event profiles, safety, and cost.
For pregnant patients, the guidelines recommend that nonpharmacologic approaches should be maximized, and that a decision to incorporate pharmacologic treatments should only be made after thorough discussion with the patient about risks and alternatives. Burch noted that one of the main changes in the update relates to treating pregnant patients or patients planning to become pregnant, which has been a focus of recent research.
Clinicians should check how well treatments are working after eight to 12 weeks, per the recommendations.
Expert Perspectives on Access and Complexity
"Guidelines are one way that groups like the AAN and the AHS can help improve patient outcomes," said Joanna Kempner, a sociology professor at Rutgers University who studies the politics of pain and was not involved in the recommendations. "A strong recommendation provides physicians with much-needed ammunition in their fights for prior authorization." However, Kempner noted that better outcomes depend on patients' ability to seek and afford health care.
Andrew Charles, director of the UCLA Goldberg Migraine (搜索) Program and immediate past president of the headache society, expressed concern about the complexity of the recommendations. "Frankly, I think it's going to scare away primary care doctors from using it because of how complicated it is," Charles said.
Charles and Kempner both pointed out that candesartan, a generic hypertension medication often used to treat migraine (搜索) in the U.S. and Europe, was described in the guidelines as having "insufficient evidence to support its use," despite being well tolerated, more affordable than other treatments, and effective in several placebo-controlled studies.
The guidelines also downplayed rimegepant, a CGRP-blocking medication sold under the brand name Nurtec and approved by the FDA in 2021 as a preventive treatment for episodic migraine (搜索). The guidelines recommend rimegepant for patients with episodic migraine only if they do not respond to medications "with higher evidence."
"Payers will often find any reason they can to not approve access to a specific medication," said Charles, who has worked as a consultant for several companies that make migraine (搜索) treatments listed in the guidance. "If you create these multiple layers of qualifications, then that provides an opportunity for the payers to decline coverage."
Burch said she did not believe the new guidelines would contain anything clinicians would find unexpected or surprising. "One of the goals with this guideline was to be clear about who is eligible for prevention, and it really is more people than are receiving preventive treatment right now," she said. "My hope is that this guideline helps clinicians feel more comfortable prescribing preventive treatments for people with migraine (搜索)."