The American College of Physicians (ACP) has issued new guidelines to prevent episodic migraines among adults, specifically for primary care physicians who see patients who are not taking preventive migraine drugs previously. The preferred first-line treatment options are beta-blockers, amitriptyline, venlafaxine, and divalproex. If these are ineffective or problematic with side effects, physicians may consider calcitonin gene-related peptide (CGRP) blockage drugs such as monoclonal antibodies (eptinezumab, erenumab, fremanezumab, galcanezumab) or gepants (atogepant, rimegepant). Topiramate is a further option but only as third-line treatment with possible side effects.
Doctors should start with a low dose, gradually increase it, and monitor patient compliance, considering comorbidities, cost, preference, and pregnancy.
These guidelines represent a shift from the earlier ACP migraine prevention guidelines published in 2003. The new edition for the first time addresses CGRP inhibitors and gives more emphasis to economic factors and patient values.
Yet, the ACP guidelines are contrary to those of the American Headache Society (AHS), which suggests the use of CGRP inhibitors as first-line therapy based on their effectiveness and improved tolerability. The International Headache Society also endorses migraine-specific therapy if available. The use of valproate is discouraged by experts in women of childbearing age because of severe health consequences. Others also feel that CGRP inhibitors should be given priority because they enhance quality of life and decrease migraine-related disability. Though the ACP guidelines are a formal process, they are based on lower-grade evidence for older drugs, the majority of which have more side effects and higher discontinuation rates.
Source: www.jwatch.org/na58418/2025/03/17/new-american-college-physicians-guidelines-prevention
