Two or three times a week, a throbbing pain settles in behind one eye. Light hurts, and the smell of coffee turns her stomach. She takes an over-the-counter pain reliever, lies down and loses most of an afternoon. Over a few months the headaches come more often, and she takes more pills to keep up with them.
That pattern is a common way for migraine care to go wrong. In a large US survey published in 2007, about 39% of people with migraine had attacks frequent or disabling enough that a panel of headache experts said prevention should be offered or at least considered. Only 13% were using a daily preventive medicine. The data are old, but the problem persists: in December 2025 the American Headache Society (AHS) still called migraine underdiagnosed and undertreated.
Migraine is a neurological disease with formal diagnostic rules, not simply a bad headache. A 2024 commentary in Cephalalgia, the International Headache Society’s journal, reported that the Global Burden of Disease study’s 2021 update put migraine first among neurological causes of lost healthy life in children and teenagers and second only to stroke in adults under 60. It affects an estimated 1.16 billion people worldwide.
What makes a headache a migraine
For migraine without aura, the International Classification of Headache Disorders (ICHD-3), the 2018 rulebook clinicians use, asks for at least five attacks, each lasting 4 to 72 hours if untreated, or as little as 2 hours in children and teens. The pain must have at least two of four features: it sits on one side, it pulses, it is moderate or severe, and routine activity such as climbing stairs makes it worse or makes the person avoid such activity. Each attack also brings nausea or vomiting, or sensitivity to both light and sound.
The headache is only one phase. The National Institute of Neurological Disorders and Stroke (NINDS) describes an early warning stage, the prodrome, and a recovery stage, the postdrome, that can last up to two days.
Aura
Only some people get aura: brief, fully reversible neurological symptoms, most often visual, such as flickering lights, but sometimes pins and needles, numbness or trouble with speech. ICHD-3 looks for features such as a symptom that spreads gradually over five minutes or more, symptoms that each last 5 to 60 minutes, and a headache that arrives during the aura or within an hour. The classification notes that this version of its criteria did a better job of telling aura apart from a transient ischemic attack, a short-lived, stroke-like event.
Who gets it
Women are affected far more often than men, but the size of the gap depends on the measure. The American Migraine Prevalence and Prevention study applied formal diagnostic criteria to 162,576 Americans aged 12 and older and found migraine in 17.1% of women and 5.6% of men, roughly three to one. Federal health surveys ask a broader question that counts migraine and severe headache together. By that yardstick, a 2021 analysis in the journal Headache found 21% of women and 10.7% of men affected in 2018, about two to one, and 15.9% of all US adults, along with roughly 4 million emergency visits for migraine in 2016. NINDS links the sex difference partly to hormone shifts around the menstrual cycle and pregnancy.
When pain relievers start causing headaches
The belief that does the most damage is that more pain medicine can’t make headaches worse. It can. ICHD-3 defines medication-overuse headache as headache on 15 or more days a month in someone who already has a headache disorder, after more than three months of regular use of drugs taken to stop attacks. Depending on the drug, “regular” means 10 or more days a month, or 15 or more. The classification is candid that those day counts come from expert opinion rather than formal evidence.
It is common among people with frequent headaches. ICHD-3 reports that, in many countries, more than half of people with headache on 15 or more days a month have it, and that most improve once the overused drug is discontinued. Getting there safely, and deciding what takes the drug’s place, is work for the clinician treating the headaches, because the migraine underneath still needs a plan.
The National Library of Medicine’s MedlinePlus page on sumatriptan, one of the triptan drugs, draws a simpler line. It says not to use it or any other headache medicine on more than 10 days a month, and to call the doctor if it is needed for more than four headaches in a month.
Treating the attack itself
NINDS lists the drug families used during an attack: over-the-counter pain relievers, triptans, ergot derivatives, anti-nausea medicines and newer drugs aimed at CGRP (calcitonin gene-related peptide), a signaling protein involved in migraine pain. In March 2025 the American College of Physicians (ACP) made a strong recommendation, based on moderate-certainty evidence, that clinicians add a triptan for nonpregnant adults with moderate to severe attacks when a nonsteroidal anti-inflammatory drug (NSAID) alone does not work well enough.
Triptans carry a specific warning. MedlinePlus says pain, tightness or pressure in the chest, throat, neck or jaw, weakness or numbness in an arm or leg, slow or difficult speech, or a fast or irregular heartbeat after a dose calls for immediate medical help.
Prevention: who it is for
Prevention means regular treatment to cut the number of attacks. On 31 August 2026 the American Academy of Neurology (AAN) and the AHS published a new joint guideline on preventive drugs for adults, updating their 2012 version. The American Academy of Family Physicians endorsed it.
It starts with who should hear about prevention at all. Clinicians should tell everyone with migraine that effective preventive treatments exist. They should offer prevention to people with four or more migraine days a month, and to people with substantial disability from migraine. All three recommendations are Level B, the guideline’s “should” tier.
The drugs fall into a handful of families. Older options include beta-blockers such as propranolol and metoprolol, the antiseizure drugs topiramate and valproate, and antidepressants such as amitriptyline. Injections of onabotulinumtoxinA are used for chronic migraine, the more frequent form. The newer CGRP-targeting drugs include four monoclonal antibodies, eptinezumab, erenumab, fremanezumab and galcanezumab, given by injection or infusion, and two gepants, atogepant and rimegepant, taken by mouth.
Three US medical groups, three different rankings
The CGRP drugs are where expert opinion splits, and the split is genuine.
The American headache society, 2024. In a position statement from its board, the AHS wrote: “The CGRP-targeting therapies should be considered as a first-line approach for migraine prevention along with previous first-line treatments…” The rest of the sentence says patients should not have to fail other drug classes first. The board judged the evidence for these drugs to exceed that for any other preventive approach and found serious side effects rare. It is a consensus statement, not a graded guideline.
The AAN and AHS, 2026. The joint guideline does not crown one family. It sorts choices by what matters most to the patient, all at Level B:
- If effectiveness comes first: the four antibodies, atogepant, propranolol, topiramate or valproate for episodic migraine.
- If side effects are the worry: the four antibodies or atogepant.
- If unknown long-term harms are the worry: drugs with a long track record, propranolol or topiramate for episodic migraine.
- If cost is the worry: less expensive options, chosen with the patient’s insurance and formulary in mind.
The American college of physicians, 2025. ACP’s guideline for episodic migraine (1 to 14 headache days a month) in nonpregnant adults puts an older oral drug first: a beta-blocker (metoprolol or propranolol), valproate, venlafaxine or amitriptyline. A gepant or CGRP antibody comes second, for people who do not tolerate or respond to those, and topiramate third. All three recommendations are conditional and rest on low-certainty evidence. ACP’s announcement said its committee found almost no differences in clinical net benefit among the drugs, so it made economic evidence and patient preferences primary factors.
Why they disagree
The argument is less about whether the newer drugs work than about weighing tolerability against cost. The AHS stresses that the older first-line drugs were borrowed from other conditions and that many people struggle to stay on them because of side effects or weak results. ACP, seeing little difference in net benefit, gave cost and patient preferences the deciding weight. The AAN and AHS split the difference by asking which concern a particular patient has.
Beneath all three sits a gap in the research. The systematic review behind the 2026 guideline, covering 217 studies, found that evidence comparing one active drug with another was limited and mostly of low or very low confidence. Until that changes, the order in which people try them is partly a judgment about values.
Safety points the 2026 guideline singles out
- Pregnancy (level a). People who could become pregnant must be told about fetal risks, and drugs known to cause birth defects, such as valproate and topiramate, should be avoided if possible. For people who are pregnant or planning to be, the guideline says to make the most of non-drug approaches.
- Hormones (level a). Topiramate can make hormonal contraception less effective at higher doses, and valproate can raise the risk of polycystic ovary syndrome. Preventive drugs also pass into breast milk.
- Older adults. Clinicians should check for vascular disease, drug interactions and kidney and liver function, and discuss blood pressure dropping on standing; amitriptyline raises the risk of urinary retention in older men.
- Patience. The guideline says to wait at least 8 to 12 weeks at a tolerated dose before judging a drug, or 24 weeks for onabotulinumtoxinA, and to discuss tapering after six months.
Questions to bring to a prevention appointment
- How many migraine days do I have in a typical month, and does that meet the point where prevention is offered?
- Could the medicine I take during attacks be adding to the headaches?
- What matters most to me right now: effectiveness, side effects, a long track record or cost? Which options fit that priority?
- Could I become pregnant, or do I use hormonal contraception? How does that narrow the choices?
- How will we judge whether a preventive is working, and after how long?
Butterbur, feverfew, magnesium and riboflavin: what the grades say
A common claim is that neurologists recommend butterbur and feverfew. That was once partly true, and the details matter.
In 2012 the AAN and AHS rated butterbur (Petasites) Level A: effective, and should be offered. They rated one specific feverfew extract, magnesium and riboflavin (vitamin B2) Level B, probably effective, alongside several NSAIDs. On 16 September 2015 the AAN retired that entire guideline. Its notice gives no reason.
The stated reason comes from the National Center for Complementary and Integrative Health (NCCIH), a federal agency, not from the academy’s notice. NCCIH’s headache fact sheet says the academy stopped recommending butterbur in 2015 because of serious concerns about possible liver toxicity. The culprits are plant chemicals called pyrrolizidine alkaloids, which NCCIH says can damage the liver and lungs and may cause cancer. Products processed to remove them are sold as “PA-free,” but NCCIH reports rare cases of liver injury with products described that way. It also says products containing the alkaloids should not be used during pregnancy or breastfeeding, and warns of allergic reactions in people sensitive to ragweed and related plants.
So butterbur has positive trial evidence for one root extract, but in this library’s terms documented harm leads, and no current US guideline recommends it. The 2026 AAN/AHS guideline names no supplement at all.
NCCIH’s fact sheet, last updated in 2021, summarizes the reviews for the rest:
- Magnesium. A 2018 review of 5 studies with 253 people found it possibly effective at reducing how often attacks happen. Doses used for migraine exceed the safe upper limit for magnesium from supplements, so NCCIH says it should be used only under a health care provider’s supervision; the library’s piece on magnesium’s upper limit explains where that ceiling comes from. High doses cause diarrhea, nausea and cramps, and it interacts with some antibiotics, diuretics and osteoporosis drugs.
- Riboflavin. A 2017 review of 9 studies with 546 people found some, but not all, studies helpful, more so in adults than in children.
- Feverfew. A 2020 review of 7 studies with 634 people found inconsistent results. Side effects include digestive upset, rash and mouth inflammation, and it may interact with medicines.
On the library’s five-verdict scale, magnesium and riboflavin hold positive evidence with a contested interpretation: small reviews, mixed results, a retired Level B rating and no current guideline. Feverfew is insufficient. Whether any of them fits alongside prescription treatment is worth raising with the prescriber, and a pharmacist can check for interactions.
Devices and non-drug approaches
The Food and Drug Administration regulates several kinds of headache device as Class II, a moderate-risk category with special controls: stimulators that pass a mild current through skin electrodes on the head, magnetic stimulators aimed at specific brain regions, and external vagus nerve stimulators, which are prescription devices.
The AHS’s 2021 consensus statement said several of these devices may be appropriate for treating or preventing attacks, as may behavioral therapies such as cognitive behavioral therapy, biofeedback, relaxation training and mindfulness; the library looks at relaxation methods on their own evidence elsewhere. NCCIH says it is unclear whether biofeedback beats a placebo. Acupuncture, where expectation may explain much of the benefit, gets a fuller hearing in the library’s acupuncture piece, and tracking personal triggers is a subject of its own.
Aura, stroke and estrogen
Migraine with aura carries a higher risk of one kind of stroke. A 2009 meta-analysis in The BMJ pooled case-control and cohort studies and linked migraine with aura to about twice the relative risk of ischemic stroke, the kind caused by a blocked artery. Migraine without aura showed no clear increase. The risk was higher still in people under 45, smokers and women taking oral contraceptives. These are observational findings, and a relative risk is a multiplier on someone’s starting risk, not the risk itself.
That is why federal contraception guidance treats aura as a firm line for estrogen. CDC’s 2024 US Medical Eligibility Criteria for Contraceptive Use put combined hormonal contraception, meaning pills, patches and rings that contain estrogen, in Category 4 for people with migraine with aura, meaning CDC judges the combination an unacceptable health risk. For migraine without aura, the same methods are Category 2, where the benefits usually outweigh the risks. Progestin-only pills, the injection, the implant and both kinds of IUD are Category 1, with no restriction, for every headache type. For anyone with aura, which method fits is a specific question for the prescriber.
Red flags that point beyond migraine
Most headaches, migraine included, are not caused by another condition. A minority signal something else, such as bleeding, infection or a tumor. A 2019 review in Neurology gathered the warning signs into a screening list called SNNOOP10. Grouped for readers, they include:
- A sudden or abrupt onset
- Fever or other whole-body symptoms, a history of cancer, or a weakened immune system such as from HIV
- Any neurological change, including weakness, numbness, confusion or reduced alertness, or swelling at the back of the eye that a clinician finds
- A first headache after 65, a new headache, a clear change in an old pattern, or a headache that keeps getting worse
- Headache that changes with position, or that coughing, sneezing or exercise sets off
- Headache during pregnancy or after giving birth
- Headache after a head injury
- A painful eye with certain accompanying eye signs
- Heavy painkiller use, or a new medicine started around the time the headaches began
The authors note that no prospective studies have tested these flags, so they raise suspicion rather than settle anything. Any of them warrants a medical evaluation, not another round of the usual remedy. NINDS notes that an attack lasting more than three days can require hospital care.
A sudden, severe headache together with weakness, numbness, trouble speaking or confusion is an emergency. Call 911.
The two numbers that shape migraine care
Two counts drive most decisions: migraine days a month, and days a month on medicine to stop an attack. Four or more migraine days is where the 2026 guideline says prevention should be offered. More than 10 medicine days is where MedlinePlus draws its line and where medication-overuse headache becomes a real possibility. Once either number crosses its line, the question for a clinician shifts from which pain reliever works fastest to whether prevention is overdue, and which kind fits the trade-off that matters most to you: effectiveness, side effects, track record or cost.
Sources
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