The American College of Physicians (ACP) recently published migraine prevention guidelines. The recommendations are based on a systematic review and network meta-analysis that they performed and are intended for nonpregnant adults with episodic migraine (defined as 1 to 14 headache days per month). Key recommendations include:

• First-line therapies: Beta-blocker (metoprolol or propranolol), valproate, venlafaxine, amitriptyline
• Second-line therapies: CGRP receptor antagonists (atogepant, rimegepant) or CGRP antibodies (eptinezumab, erenumab, fremanezumab, or galcanezumab)
• Third-line therapy: Topiramate

All of the guidelines are based on low-certainty evidence, as there are few meaningful head-to-head trials comparing migraine drugs. Their reasoning for recommending CGRP drugs over topiramate is that topiramate has a less favorable side effect profile.

Migraine prevention has always been the Wild West of pharmacotherapy, as a broad range of medications with seemingly unrelated mechanisms are used for treatment. Fortunately, most recommended drugs are affordable. The newer CGRP drugs are expensive and have modest efficacy in trials, reducing average migraine days per month by 1 - 2 compared to placebo. Notably, placebo typically performs well in migraine trials, likely reflecting overdiagnosis, as patients and some providers tend to label all headache syndromes as migraines.

• Migraine headache review
• Migraine headache medications