Migraine is diagnosed according to International Headache Society (IHS) criteria into migraine without aura, migraine with aura, probable migraine, and chronic migraine,1 and treatment is focused on the acute treatment of migraine attacks and preventive medication.2
Medicines for acute treatment of migraine attacks2,3
Most people with migraine use non-prescription analgesics, such as aspirin, paracetamol and codeine (and combinations with caffeine etc) to treat migraine attacks. These and non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen, can be effective in mild/moderate attacks.
Other acute treatments include:
- Anti-emetics eg. metoclopramide and domperidone
- Triptans (5-HT1 agonists) eg. sumatriptan, eletriptan, naratriptan, frovatriptan and rizatriptan
- Ditans (selective 5-HT1F agonists) eg. lasmiditan
- Gepants (CGRP antagonists) eg. ubrogepant, rimegepant, atogepant and zavegepant
Medicines for prevention of migraine attacks2-4
Prophylactic migraine treatment is recommended for patients with one or more of:
- Four or more monthly headache days
- Migraine has an impact on personal, social, and professional life according to personal patient perception
- Optimised acute treatment is ineffective in providing migraine relief
- Acute medications are used frequently to treat attacks
Drugs classes for migraine prevention include:
- Beta-blockers eg. propranolol and metoprolol
- Anticonvulsants eg. topiramate and sodium valproate
- Calcium channel blockers eg. flunarizine
- Angiotensin II blockers eg. candesartan
- Antidepressants eg. amitriptyline and nortriptyline
- CGRP monoclonal antibodies (mAbs) eg. erenumab, fremanezumab, galcanezumab, eptinezumab
- Gepants eg. rimegepant and atogepant
- Onabotulinumtoxin A
The role of anti-CGRP therapies
In 2024, the American Headache Society (AHS) recommended that CGRP-targeting therapies should be considered as a first-line approach for migraine prevention, without a requirement for prior failure of other classes of migraine preventive treatment.5 This recommendation was based on substantial evidence for the efficacy, tolerability, and safety of CGRP-targeting migraine preventive therapies – CGRP mAbs and gepants – ‘vastly exceeding’ that for any other preventive treatment approach. The position statement concluded that:
- The evidence is consistent across different individual CGRP-targeting treatments and corroborated by extensive real world clinical experience
- The data indicate that the efficacy and tolerability of CGRP-targeting therapies are equal to or greater than those of previous first-line therapies and that serious adverse events associated with CGRP-targeting therapies are rare.
In 2025, the IHS proposed ambitious goals for real world practice aimed at complete migraine freedom with normal or near-normal quality of life, and confirmed that anti-CGRP therapies have proved effective and better tolerated than previous therapies.6 The statement added that consistent results with these agents and onabotulinumtoxinA indicate that meaningful reductions, and even the elimination of disability as a result of migraine, are now a real possibility for some individuals with migraine.6
References
- Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018 Jan;38(1):1-211.
- Ferrari MD, Goadsby PJ, Burstein R et al. Migraine. Nat Rev Dis Primers. 2022 Jan 13;8(1):2.
- Ornello R, Caponnetto V, Ahmed F et al. Evidence-based guidelines for the pharmacological treatment of migraine. Cephalalgia. 2025 Apr;45(4):3331024241305381.
- Puledda F, Sacco S, Diener HC et al. International Headache Society Global Practice Recommendations for Preventive Pharmacological Treatment of Migraine. 2024 Sep;44(9):3331024241269735.
- Charles AC, Digre KB, Goadsby PJ et al; American Headache Society. Calcitonin gene-related peptide-targeting therapies are a first-line option for the prevention of migraine: An American Headache Society position statement update. Headache. 2024 Apr;64(4):333-341.
- Sacco S, Ashina M, Diener HC et al. Setting higher standards for migraine prevention: A position statement of the International Headache Society. Cephalalgia. 2025 Feb;45(2):3331024251320608.
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