The American College of Physicians (ACP) has developed new recommendations to prevent episodic migraines in nonpregnant adults in outpatient settings. The clinical guideline, which includes three recommendations centered around monotherapy, is published in Annals of Internal Medicine.

In Recommendation 1, ACP suggests clinicians initiate monotherapy to prevent episodic migraine headache in nonpregnant adults in outpatient settings by choosing one of the following pharmacologic treatments: a beta-adrenergic blocker, either metoprolol or propranolol; the antiseizure medication valproate; the serotonin and norepinephrine reuptake inhibitor venlafaxine; or the tricyclic antidepressant amitriptyline.

In Recommendation 2, if these patients do not tolerate or inadequately respond to a trial or trials of treatments in Recommendation 1, then ACP suggests that clinicians use monotherapy with a calcitonin gene-related peptide (CGRP) antagonist (atogepant or rimegepant) or a CGRP monoclonal antibody (eptinezumab, erenumab, fremanezumab, or galcanezumab). In Recommendation 3, if patients still do not tolerate or inadequately respond to a trial or trials of treatments suggested in Recommendations 1 and 2, then ACP suggests clinicians use monotherapy with the antiseizure medication topiramate.

Migraine is characterized by recurrent episodes of usually moderate-to-severe intensity headache lasting 4 to 72 hours with or without sensory disturbances, generally pulsating and often accompanied by nausea, vomiting, or aversion to light or sound. Because the condition remains under-diagnosed and under-treated, only a small percentage of eligible people receive preventive pharmacologic treatments.

ACP considered the findings from an accompanying comparative effectiveness systematic review that used the GRADE approach to analyze the effects of pharmacologic treatment to prevent episodic migraine headache on the following outcomes: migraine frequency and duration, number of days medication was taken for acute treatment of migraine, frequency of migraine-related emergency room visits, migraine-related disability, quality of life and physical function, and discontinuations due to adverse events. Additional data about adverse events were identified through Food and Drug Administration medication labels and eligible studies.

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Because of the lack of differences in clinical net benefit between virtually all treatments, the CGC used economic evidence and patients’ values and preferences data as primary factors in prioritizing different migraine prevention treatments. The median annual costs of recommended initial oral treatments varied substantially.

The guideline emphasizes that a patient’s adherence to pharmacologic treatment is crucial because improvement may occur gradually after initiating a long-term treatment option for preventing episodic migraine, with an effect that may become apparent after the first few weeks of treatment.