Prevention of Episodic Migraine Headache Using Pharmacologic Treatments in Outpatient Settings: A Clinical Guideline From the American College of Physicians

The American College of Physicians (ACP) developed this clinical guideline for clinicians caring for adults with episodic migraine headache (defined as 1 to 14 headache days per month) in outpatient settings.

Methods: ACP based these recommendations on systematic reviews of the comparative benefits and harms of pharmacologic treatments to prevent episodic migraine, patients' values and preferences, and economic evidence. ACP evaluated the comparative effectiveness of the following interventions: angiotensin-converting enzyme inhibitors (lisinopril), angiotensin II-receptor blockers (candesartan and telmisartan), antiseizure medications (valproate and topiramate), β-blockers (metoprolol and propranolol), calcitonin gene-related peptide (CGRP) antagonist-gepants (atogepant or rimegepant), CGRP monoclonal antibodies (eptinezumab, erenumab, fremanezumab, or galcanezumab), selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors (fluoxetine and venlafaxine), and a tricyclic antidepressant (amitriptyline). ACP used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to analyze the effects of pharmacologic treatment on the following outcomes: migraine frequency and duration, number of days medication was taken for acute treatment of migraine, frequency of migraine-related emergency department visits, migraine-related disability, quality of life and physical functioning, and discontinuations due to adverse events. In addition, adverse events were captured through U.S. Food and Drug Administration medication labels and eligible studies.

Recommendations: In this guideline, ACP makes recommendations for clinicians to initiate monotherapy for episodic migraine prevention in nonpregnant adults in the outpatient setting as well as alternative approaches if initial treatments are not tolerated or result in an inadequate response. All 3 ACP recommendations have conditional strength and low-certainty evidence. Clinical considerations provide additional context for physicians and other clinicians.