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give recent guidelines on headache?
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headache migraine guidelines management
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headache management guidelines 2025 2026 AAN IHS
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PMID: 41321235
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headache classification ICHD diagnosis primary secondary
Here is a synthesis of the most current headache guidelines, drawing from the 2025 American Headache Society (AHS) update, recent systematic reviews, and standard emergency medicine references.
Recent Headache Guidelines (2025-2026)
1. Classification of Headaches (ICHD-3 Framework)
Headaches are broadly classified as:
- Primary headaches: Migraine, tension-type headache (TTH), cluster headache, other trigeminal autonomic cephalalgias (TACs)
- Secondary headaches: Due to infection, vascular disorders, intracranial hypertension, trauma, medication overuse, etc.
- Red flags (SNOOP4) that suggest secondary cause:
- Systemic signs (fever, weight loss, malignancy)
- Neurological deficits
- Onset sudden (thunderclap)
- Older age of onset (>50 years)
- Progressive pattern / Postural change / Precipitating factors (Valsalva) / Papilledema
2. Migraine Management - Acute Treatment
Outpatient / Home Setting
| Drug Class | Examples | Notes |
|---|---|---|
| NSAIDs | Ibuprofen, naproxen, ketorolac | First-line for mild-moderate migraine |
| Triptans | Sumatriptan, rizatriptan, eletriptan | First-line for moderate-severe migraine; avoid in cardiovascular disease, hemiplegic/basilar migraine |
| CGRP antagonists (gepants) | Ubrogepant, rimegepant | Newer oral agents; safe in cardiovascular disease; no vasoconstriction |
| Ditans | Lasmiditan | 5-HT1F agonist; no vasoconstriction; dizziness common |
| Antiemetics | Metoclopramide, prochlorperazine | Useful adjuncts; also treat nausea |
3. Emergency Department (ED) Migraine - 2025 AHS Guideline Update (PMID: 41321235)
This is the most significant recent guideline, published January 2026 in Headache and affirmed by the American Academy of Neurology (AAN).
Recommendation Levels
Level A - MUST Offer
- IV Prochlorperazine - strongest evidence from multiple Class I RCTs
- Greater Occipital Nerve Block (GONB) - now elevated to Level A for the first time
Level A - MUST NOT Offer
- IV Hydromorphone (and IV opioids broadly) - safer, more effective alternatives exist; opioids now formally contraindicated
Level B - SHOULD Offer
- IV Dexketoprofen
- IV Ketorolac
- IV Metoclopramide
- SC Sumatriptan
- Supraorbital Nerve Block (SONB)
- IV Eptinezumab (CGRP antagonist) - Level B for patients matching trial criteria; first parenteral CGRP antagonist evaluated in ED guidelines
Level C - MAY Offer
- IV Chlorpromazine
- IV Dexamethasone (adjunct to reduce recurrence)
- IV Valproate
Level C - MAY NOT Offer
- IV Paracetamol (acetaminophen) - unlikely effective parenterally
Level U - Insufficient Evidence
- Caffeine, granisetron, ketamine, lidocaine, propofol, SPG blocks - need more RCT data
Key takeaway: This guideline is the first ED migraine guideline with Level A recommendations (none existed in 2016). The shift away from opioids is now formal and evidence-based. Nerve blocks have been substantially elevated. - 2025 AHS ED Guideline
4. Migraine Prevention (Prophylaxis)
Oral preventives (established)
| Drug | Class | Notes |
|---|---|---|
| Topiramate | Anticonvulsant | Level A evidence |
| Valproate | Anticonvulsant | Avoid in pregnancy |
| Propranolol / metoprolol | Beta-blockers | Level A |
| Amitriptyline / nortriptyline | TCAs | Level B |
| Candesartan / lisinopril | ARB/ACE | Level B |
| Venlafaxine | SNRI | Level B |
CGRP-targeted preventives (newer, 2018-2025)
| Drug | Route | Frequency |
|---|---|---|
| Erenumab (Aimovig) | SC | Monthly |
| Fremanezumab (Ajovy) | SC | Monthly or quarterly |
| Galcanezumab (Emgality) | SC | Monthly |
| Eptinezumab (Vyepti) | IV | Quarterly |
| Atogepant / Rimegepant | Oral | Daily / every other day |
CGRP-targeted therapies are now recommended as first-line options for patients with frequent migraine who fail or cannot tolerate older preventives.
5. Cluster Headache (Trigeminal Autonomic Cephalgia)
- Acute attack: 100% oxygen (12-15 L/min via non-rebreather mask) for 15 minutes; SC or intranasal sumatriptan; intranasal zolmitriptan
- Preventive: Verapamil (drug of choice); short-course corticosteroids for episodic cluster; lithium, topiramate as alternatives
- Newer option: Galcanezumab - FDA-approved for episodic cluster headache
6. Tension-Type Headache (TTH)
- Acute: Simple analgesics (ibuprofen, aspirin, paracetamol); caffeine combinations
- Chronic TTH prevention: Amitriptyline (first-line); stress management, physiotherapy, biofeedback
7. Non-Pharmacological Approaches (2026 Evidence)
Recent systematic reviews support:
- Cervical strengthening/stabilization exercises - benefit in migraine management (PMID: 42501000)
- Acupuncture - effective for chronic daily headache prophylaxis (PMID: 42177613)
- Digital/virtual interventions (apps, biofeedback tools) - growing evidence in migraine management (PMID: 41776980)
- Medical hypnosis - emerging evidence for migraine management (PMID: 41974234)
8. Special Situations
| Situation | Recommendation |
|---|---|
| Medication overuse headache (MOH) | Withdraw the overused drug; transition to preventive therapy; avoid opioids/triptans >10 days/month |
| Pregnancy | Paracetamol (acetaminophen) safest; avoid NSAIDs in 3rd trimester; avoid ergotamine, valproate (category X); magnesium may be used |
| Pediatric migraine | Ibuprofen and sumatriptan nasal spray (older children); topiramate or amitriptyline for prevention |
| Thunderclap headache | Always investigate - rule out subarachnoid hemorrhage (CT head non-contrast, then LP if CT negative) |
Summary of Key 2025-2026 Changes
- Opioids are now formally contraindicated (Level A - must NOT offer) in ED migraine - the strongest evidence statement ever made against them.
- Nerve blocks (GONB) elevated to Level A in ED management - cheap, safe, highly effective.
- CGRP antagonists (gepants, CGRP mAbs) are now mainstream, not just add-ons.
- Non-drug therapies (exercise, acupuncture, digital tools) have strong systematic review-level support.
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