Migraine Prevention Medicines: Which Ones Work Best?

A large 2026 review of 217 trials by the American Academy of Neurology and American Headache Society found that CGRP-targeted drugs (erenumab, galcanezumab and others), older tablets such as propranolol and topiramate, and Botox for chronic migraine all reduce headache days better than placebo [1]. No single drug was shown to be better than the rest, so the choice depends on your migraine pattern, other health conditions and side effects.

Migraine Prevention Medicines at a glance

• Who it is for: adults with frequent or disabling migraine, not people with an occasional attack [1].
• Strongest evidence, episodic migraine: galcanezumab and erenumab (high confidence) [1].
• Strongest evidence, chronic migraine: fremanezumab, galcanezumab and onabotulinumtoxinA (high confidence) [1].
• Older tablets: propranolol, topiramate and valproate have moderate-confidence evidence [1].
• Head-to-head data: limited, so no drug can be called the winner [1].
• Mood: anxiety and depression scores also fell with CGRP drugs, though this is not proof they treat those conditions [3].

What did the new review actually look at?

The joint panel of the American Academy of Neurology and American Headache Society gathered randomised trials of preventive migraine drugs in adults. They searched the literature up to June 2024 and ended up with 217 studies [1]. For each drug they measured change in monthly headache days, how many people had at least half their headache days removed, and quality-of-life scores. They then graded how confident they were in each result.

This was a review of the evidence, not a ruling on which drug to prescribe. Recommendations come in a companion guideline [1].

Which medicines have the strongest evidence?

For episodic migraine, galcanezumab and erenumab came out with high-confidence evidence of fewer headache days than placebo. Atogepant, eptinezumab, fremanezumab, propranolol, topiramate and valproate had moderate-confidence evidence [1].

For chronic migraine, meaning headache on 15 or more days a month, fremanezumab, galcanezumab and onabotulinumtoxinA (Botox) had high-confidence evidence. Atogepant, eptinezumab, erenumab, topiramate and valproate had moderate-confidence evidence [1].

Several other tablets, among them amitriptyline, flunarizine, metoprolol and telmisartan, had only low-confidence evidence of possible benefit [1]. Low confidence does not mean they fail. It means the trials were too small or too uneven to be sure.

Evidence grade for common migraine preventives in adults, from the 2026 AAN/AHS review [1].

Is one preventive medicine better than the others?

Nobody can say yet. The review found that trials comparing one active drug against another were few, and the confidence in those results was low or very low [1]. So a tablet is not shown to be worse than an injection, and an injection is not shown to be better. Each was better than placebo, and that is the claim the evidence supports.

In practice this means a doctor chooses based on you. Someone with high blood pressure may do well on a beta-blocker such as propranolol. Someone who has had side effects from tablets, or who has tried two or three preventives without enough relief, may be a candidate for a CGRP injection or Botox. Pregnancy, planned pregnancy, weight, mood and other medicines all matter.

Can migraine medicines also help anxiety and depression?

Migraine and mood problems often travel together. A 2026 meta-analysis of 12 studies and 3,603 adults found that depression and anxiety scores fell after three months on CGRP-targeted drugs, on several different rating scales [3]. The authors point out that those improvements tracked with better migraine control. The studies could not separate a direct effect on mood from the relief of having fewer attacks. The one placebo-controlled comparison did not show a statistically significant difference [3].

So treat this as encouraging, not settled. If low mood or anxiety is part of your picture, say so at your appointment. It deserves its own assessment and treatment.

What about procedures such as nerve blocks?

An umbrella review of 17 systematic reviews looked at procedures for chronic migraine. OnabotulinumtoxinA had the most established evidence. Greater occipital nerve blocks showed a possible short-term reduction in headache days, but the certainty was low and long-term benefit was unclear. Evidence for implanted nerve stimulators, acupuncture and other procedures was limited, and most results were rated low or very low certainty [2]. The authors stress that procedures should not be treated as one group. Each needs to be judged on its own evidence and on the person in front of the doctor [2].

How do you know if you need a preventive at all?

A preventive is usually discussed when migraine is frequent, disabling, or not controlled by treatment taken during attacks. Many neurologists use around three or more disabling attacks a month as a rough starting point, though this is a clinical habit and not a rule from this review.

Two things help before you see anyone. Keep a headache diary for a few weeks, noting the days, how long each lasted, what you took and whether it worked. And count how many days a month you take painkillers, because frequent use can itself keep headaches going.

Prevention is slow. Doctors usually ask you to give a new medicine a couple of months before judging it, so talk to them before stopping early, especially if a side effect worries you.

When should you get urgent help?

A sudden, severe "worst ever" headache, headache with weakness, confusion, trouble speaking, fever with a stiff neck, or a first migraine-like headache after the age of 50 needs urgent medical attention. Call 112 or go to the nearest emergency department. If persistent low mood or hopelessness is part of what you are going through, Tele-MANAS (14416) is free and available 24 hours a day.

Getting help in Delhi

At Brain Bridge Clinic in Safdarjung Enclave, New Delhi, a migraine assessment starts with your history: how often the attacks come, how long they last, what you take for them and what has already been tried. We go through your diary if you have kept one, check for other health conditions that affect which medicine is safe for you, and screen for mood and sleep problems that often sit alongside migraine. From there we discuss preventive options, including CGRP-targeted therapy and Botox where they fit the evidence, and agree a plan with a review date. If you would like an assessment, you can book one through the clinic.

Related pages: Migraine Cluster Headache, Cgrp Preventive Therapy, Botox For Migraine.

Frequently asked questions

Do I have to take migraine prevention medicine for life?

Not necessarily. The review summary covers how well drugs work, not how long to continue them. Your doctor will usually review the plan after a trial period and discuss whether to continue, reduce or stop.

Are CGRP injections better than tablets like topiramate?

The review could not say. Both groups beat placebo, but trials comparing them directly were few and low in certainty [1]. The right choice depends on your history, side effects and other health conditions.

Does Botox work for all types of migraine?

In this review, onabotulinumtoxinA had high-confidence evidence for chronic migraine, meaning headache on 15 or more days a month [1]. The review summary does not grade it for episodic migraine, so it is generally discussed for the chronic type.

How long does a preventive take to work?

It varies by medicine, but doctors usually ask for a trial of a couple of months before judging it. Your doctor will tell you what to expect from the specific medicine.

Can migraine treatment improve my mood?

Anxiety and depression scores fell in people on CGRP-targeted drugs, mostly alongside better migraine control [3]. The studies cannot show whether the drugs act on mood directly.

Is it safe to take preventive medicine with my usual painkillers?

Often yes, but combinations matter, and frequent painkiller use can make headaches worse. Tell your doctor everything you take, including over-the-counter and Ayurvedic products.

References

1. Pringsheim T, Smith DB, Tanveer S, et al. Systematic Review of Pharmacologic Treatment for Migraine Prevention in Adults: Report of the AAN Guidelines Subcommittee and the American Headache Society. Neurology. 2026;107(7):e218112. doi:10.1212/WNL.0000000000218112. PMID 42673559.
2. Xia L, Yang D, Lu Y, et al. Procedural interventions for chronic migraine: an umbrella review intervention-specific evidence map. Frontiers in neurology. 2026;17:1915292. doi:10.3389/fneur.2026.1915292. PMID 42935666.
3. Al-Sayegh Z, Al-Khazali S, Al-Khazali HM, et al. Depressive and anxiety symptoms during CGRP-targeted migraine prevention: A systematic review and meta-analysis. Cephalalgia : an international journal of headache. 2026;46(9):3331024261484898. doi:10.1177/03331024261484898. PMID 42731077.