This transcript has been edited for clarity.
Today we are going to discuss the new recommendations from the American College of Physicians (ACP) on pharmacologic treatment of episodic migraine headaches, which are defined as migraine headaches that occur 1-14 days a month. This is an important area for those of us in primary care because we see patients with migraines quite frequently — about 1 in 6 US adults have migraines— and some of the recommendations for treatment have changed over the past few years.
I’m going to go over the recommendations from the ACP and I’ll also point out an area where the ACP recommendation differs from the recent position statement from the American Headache Society (AHS).
First, it's important to realize that the choice to initiate ongoing therapy for prevention of migraines is a matter of clinical judgement that should be a product of shared decision-making and an ongoing discussion with your patient. Some patients get a headache once or twice a month, take an acute reliever medication that resolves their pain, and go on their way. Those patients don’t need preventive therapy. However, others may have more frequent headaches or more severe headaches that interfere with function and don’t resolve easily. The degree of discomfort, the efficacy (or lack thereof) of reliever medication, the disruption to daily function, and personal goals all influence a patient’s desire to prevent headaches and can help you determine whether to prescribe preventive therapy.
The ACP guidelines recommend the following first-line options for preventive therapies:
For patients who do not tolerate or inadequately respond to one or more trials of these first-line agents, the following second-line treatments can be considered:
In a previous column, I discussed the AHS position statement recommending that CGRP-targeting therapies be considered a first-line option for prevention of migraines. This differs from the ACP guideline, which recommends those therapies as second-line treatment. The AHS rationale was solid, as CGRP therapies are well tolerated, safe, and have comparable (if not superior) effectiveness to traditional therapies. Because CGRP therapies are migraine-specific medications, they have less off-target effects than some of the traditional first-line medications. However, they are considerably more expensive — about 15-fold more expensive. Given this cost discrepancy, the ACP has recommended them as second-line agents.
Topiramate, which used to be a first-line agent, is now recommended in the ACP guideline only if someone does not respond adequately to both the first-line agents and a CGRP-targeting agent. The ACP's rationale for this reclassification is twofold. First, some evidence suggests that topiramate is not as effective as the other agents. Second, topiramate often has undesirable side effects, particularly in the domain of cognition.
The ACP guideline also discussed the angiotensin-converting enzyme (ACE) inhibitor lisinopril, the angiotensin receptor blockers (ARBs) candesartan and telmisartan, and the selective serotonin reuptake inhibitor (SSRI) fluoxetine, though these medications were not emphasized, as the evidence supporting their use was not as robust as the evidence for previously mentioned therapies. You’ll notice that calcium channel blockers have dropped off the list.
Common supplements used in migraine treatment, including riboflavin, feverfew, Petasites (butterbur), coenzyme Q10, and magnesium, are not mentioned in the ACP guideline. However, The Medical Letter and the AHS/American Academy of Neurology (AAN) guidelines noted that there is evidence that these supplements are effective — though the strength of evidence varies.
Remember: When we talk about migraine prevention, lifestyle issues are important. Talk to your patient about avoiding triggers, maintaining adequate hydration, and getting healthy amounts of sleep and physical activity. Cognitive-behavioral therapy has also been shown to have some efficacy in managing migraines.
From a practical point of view, when we prescribe a medication for prevention, it is important to let patients know that they may need to wait a few weeks for the preventive medications to exert a noticeable effect. If there is not an adequate response by 2-3 months, then we can try a different preventive medication.
There is one important question that the ACP guideline does not answer: Can other medications in the same class as those specifically mentioned as first-line treatments by the ACP be used for migraine prevention? For instance, can you use the SNRI duloxetine or the TCA nortriptyline, even though only the SNRI venlafaxine and the TCA amitriptyline are mentioned? Although the ACP does not issue explicit guidance here, I’d say this practice is usually fine. Further, The Medical Letter on the prevention of migraine supports that approach.
This ACP guideline is an important update and provides a clear, straightforward approach that allows us to treat the common issue of episodic migraine headaches with confidence.
COMMENTARY
How Migraine Treatment Guidelines Differ: ACP vs AHS
DISCLOSURES
| April 08, 2025This transcript has been edited for clarity.
Today we are going to discuss the new recommendations from the American College of Physicians (ACP) on pharmacologic treatment of episodic migraine headaches, which are defined as migraine headaches that occur 1-14 days a month. This is an important area for those of us in primary care because we see patients with migraines quite frequently — about 1 in 6 US adults have migraines— and some of the recommendations for treatment have changed over the past few years.
I’m going to go over the recommendations from the ACP and I’ll also point out an area where the ACP recommendation differs from the recent position statement from the American Headache Society (AHS).
First, it's important to realize that the choice to initiate ongoing therapy for prevention of migraines is a matter of clinical judgement that should be a product of shared decision-making and an ongoing discussion with your patient. Some patients get a headache once or twice a month, take an acute reliever medication that resolves their pain, and go on their way. Those patients don’t need preventive therapy. However, others may have more frequent headaches or more severe headaches that interfere with function and don’t resolve easily. The degree of discomfort, the efficacy (or lack thereof) of reliever medication, the disruption to daily function, and personal goals all influence a patient’s desire to prevent headaches and can help you determine whether to prescribe preventive therapy.
The ACP guidelines recommend the following first-line options for preventive therapies:
For patients who do not tolerate or inadequately respond to one or more trials of these first-line agents, the following second-line treatments can be considered:
In a previous column, I discussed the AHS position statement recommending that CGRP-targeting therapies be considered a first-line option for prevention of migraines. This differs from the ACP guideline, which recommends those therapies as second-line treatment. The AHS rationale was solid, as CGRP therapies are well tolerated, safe, and have comparable (if not superior) effectiveness to traditional therapies. Because CGRP therapies are migraine-specific medications, they have less off-target effects than some of the traditional first-line medications. However, they are considerably more expensive — about 15-fold more expensive. Given this cost discrepancy, the ACP has recommended them as second-line agents.
Topiramate, which used to be a first-line agent, is now recommended in the ACP guideline only if someone does not respond adequately to both the first-line agents and a CGRP-targeting agent. The ACP's rationale for this reclassification is twofold. First, some evidence suggests that topiramate is not as effective as the other agents. Second, topiramate often has undesirable side effects, particularly in the domain of cognition.
The ACP guideline also discussed the angiotensin-converting enzyme (ACE) inhibitor lisinopril, the angiotensin receptor blockers (ARBs) candesartan and telmisartan, and the selective serotonin reuptake inhibitor (SSRI) fluoxetine, though these medications were not emphasized, as the evidence supporting their use was not as robust as the evidence for previously mentioned therapies. You’ll notice that calcium channel blockers have dropped off the list.
Common supplements used in migraine treatment, including riboflavin, feverfew, Petasites (butterbur), coenzyme Q10, and magnesium, are not mentioned in the ACP guideline. However, The Medical Letter and the AHS/American Academy of Neurology (AAN) guidelines noted that there is evidence that these supplements are effective — though the strength of evidence varies.
Remember: When we talk about migraine prevention, lifestyle issues are important. Talk to your patient about avoiding triggers, maintaining adequate hydration, and getting healthy amounts of sleep and physical activity. Cognitive-behavioral therapy has also been shown to have some efficacy in managing migraines.
From a practical point of view, when we prescribe a medication for prevention, it is important to let patients know that they may need to wait a few weeks for the preventive medications to exert a noticeable effect. If there is not an adequate response by 2-3 months, then we can try a different preventive medication.
There is one important question that the ACP guideline does not answer: Can other medications in the same class as those specifically mentioned as first-line treatments by the ACP be used for migraine prevention? For instance, can you use the SNRI duloxetine or the TCA nortriptyline, even though only the SNRI venlafaxine and the TCA amitriptyline are mentioned? Although the ACP does not issue explicit guidance here, I’d say this practice is usually fine. Further, The Medical Letter on the prevention of migraine supports that approach.
This ACP guideline is an important update and provides a clear, straightforward approach that allows us to treat the common issue of episodic migraine headaches with confidence.
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
TOP PICKS FOR YOU