Summary

Updated AHS consensus on integrating newer acute and preventive migraine therapies into adult practice, building on the prior position statement without altering established treatment principles. New acute options covered include gepants (ubrogepant, rimegepant), the ditan lasmiditan, celecoxib oral solution, and remote electrical neuromodulation (REN); new preventive options include IV eptinezumab, with emerging dual-use gepants (rimegepant, atogepant). Recommendations specify when to escalate from triptans/established preventives to these newer agents and how to measure response.

Key Recommendations

Offer every patient with confirmed migraine a trial of acute pharmacologic and/or nonpharmacologic treatment, using NSAIDs/nonopioid analgesics/caffeinated combinations for mild–moderate attacks and migraine-specific agents (triptans, DHE, gepants, lasmiditan) for moderate–severe attacks or poor responders.
Reserve gepants, ditans, or neuromodulatory devices for adults with ICHD-3 migraine who have contraindications/intolerance to triptans or inadequate response to ≥2 oral triptans (validated PRO or clinician attestation).
Use nonoral formulations (SC/intranasal sumatriptan, IM/IN ketorolac, DHE SC/IN, antiemetic suppositories, IV DHE for refractory) when attacks feature severe nausea/vomiting or poor oral response.
Avoid triptans and ergots in coronary disease, PVD, uncontrolled hypertension, or significant vascular risk; gepants, ditans, and neuromodulation are preferred alternatives in these patients.
Counsel patients on lasmiditan to not drive for 8 hours after dosing; it is a Schedule V controlled substance.
Limit acute medication to an average of ≤2 headache days/week; exceeding this triggers initiation or escalation of preventive therapy.
Offer preventive therapy for ≥6 headache days/month regardless of disability, ≥4 days with some disability, or ≥3 days with severe disability; consider prevention at lower thresholds (Table 4).
Start oral preventives low and titrate slowly; give an adequate trial of ≥8 weeks at target dose before declaring failure, with continued benefit possible over 6–12 months.
Assess CGRP monoclonal antibody response after ≥3 months for monthly dosing and ≥6 months for quarterly dosing; do not require titration for injectable preventives.
Use erenumab cautiously and seek alternatives in patients with latex allergy, constipation, or preexisting hypertension given reported severe constipation and BP elevation.
Consider biobehavioral therapies (CBT, biofeedback, relaxation, mindfulness, ACT) particularly for patients preferring nonpharmacologic care, those pregnant/lactating, with medication overuse, high stress, or medication intolerance.
Define meaningful preventive response as ~50% reduction in monthly headache days plus improvements in severity, function, disability, and HRQoL using validated tools (MIDAS, HIT-6, MSQ, MPFID, MFIQ, PGIC, WPAI).

Thresholds & Doses

ICHD-3 migraine: ≥5 attacks lasting 4–72 hours with characteristic features; chronic migraine: ≥15 headache days/month for >3 months with ≥8 migraine days/month.
Medication-overuse headache: ≥10 days/month for triptans, ergots, opioids, or combination analgesics; ≥15 days/month for nonopioid analgesics, acetaminophen, NSAIDs.
Acute medication cap: average ≤2 headache treatment days per week.
Rimegepant acute dose: 75 mg ODT, maximum one 75 mg dose per 24 hours.
Ubrogepant: 50 or 100 mg per attack; ~40% of trial patients required a second dose.
Lasmiditan studied doses: 50, 100, 200 mg; no driving for 8 hours post-dose.
OnabotulinumtoxinA preventive dose: 155 units (PREEMPT protocol) given quarterly.
Eptinezumab: 100 or 300 mg IV every 3 months.
Erenumab: 70 or 140 mg SC monthly.
Fremanezumab: 225 mg monthly or 675 mg quarterly SC.
Galcanezumab: 240 mg SC loading dose then 120 mg monthly.
Preventive trial duration: ≥8 weeks at target dose for orals; ≥3 months for monthly CGRP mAbs; ≥6 months for quarterly CGRP mAbs.
CGRP mAb eligibility: age ≥18 with ICHD-3 migraine and 4–7 MMDs (with disability) or ≥8 MMDs.
Neuromodulation device age cutoffs: ≥18 for most; nVNS, REN, and sTMS cleared for ages 12–17.
Preventive treatment threshold: offer at ≥6 headache days/month, ≥4 days with some disability, or ≥3 days with severe disability.
Migraine prevalence: 18% women, 6% men; peak ages 25–55.

Citations

Acute Treatment — Indications and principles (evidence-based treatment, nonoral routes, rescue, medication overuse)
Table 1 — ICHD-3 criteria for migraine and chronic migraine
Table 2 — Acute treatments with evidence of efficacy in migraine
Table 3 — Criteria for initiating acute treatment with gepants, ditans, or neuromodulatory devices
Table 4 — Criteria for identifying patients for preventive treatment
Table 5 — ICHD-3 criteria for medication-overuse headache
Table 6 — Medications with evidence of efficacy in migraine prevention
Table 7 — Criteria for initiating CGRP/CGRP-receptor monoclonal antibodies
Recently approved acute treatments section — rimegepant, ubrogepant, lasmiditan, REN, celecoxib oral solution
Preventive Treatment — Developing treatment plans (titration, adequate trial, dual-use therapies, biobehavioral)