DESCRIPTION: 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), ß-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.
| Discipline Area | Score |
|---|---|
| Physician |  |
Physician rater
It is quite surprising to find valproate recommended as a first-line treatment, while topiramate is relegated to a last-resort, third-line position after failure of CGRP-related drugs. The extent to which affected laypeople and/or headache specialists were involved in this guideline is unclear.
Physician rater
4 clearly written recommendations that would be useful for GPs.
Physician rater
This guideline is based on systematic review and network meta-analysis of RCTs of at least 12 weeks' treatment and follow-up. Excellent study reviewing the costs, adverse effects, and efficacy of various medications in the prevention of episodic migraine, reaching practical recommendations.
Physician rater
As a primary care doctor, I frequently see patients with episodic migraines and discuss treatment options with them. This review is a nice summary of the low-quality comparative evidence we have for prescribing these meds. It's nice to have these guidelines and it's important to recognize the data isn't great. I think valproate is likely something few PCPs are reaching for; these guidelines might change that. I suspect amitriptyline and topiramate are more commonly used. It would be interesting to see whether we get more venlafaxine and less topiramate after this article.
, McMaster University