The first comprehensive, evidence-based guidance on the pharmacological options for migraine have been presented at the 2026 European Academy of Neurology (EAN) congress.

The guidelines, developed by the International Headache Society and the Italian Society for the Study of Headache, and published in Cephalalgia [link here], offer recommendations for the prevention and acute treatment of migraine, based on a systematic review of all pharmacological therapies.

The guidance on acute treatment of migraine was presented at the EAN congress in Geneva, Switzerland, by co-author Dr Volodymyr Romanenko, President of Ukrainian Headache Society and neurologist at the Ukrainian Medical Academy.

Dr Romanenko spoke to the limbic about why these guidelines were needed, how they are likely to change practice, and the ongoing challenges within migraine treatment.

Why were these guidelines necessary and how were they developed?

There are a lot of trials, research and publications going on in migraine and the field is booming. There are new agents but when you look at individual studies of their efficacy and safety, they tend to have a narrow focus on that drug.

So for the guidelines we systematically analysed almost 900 papers on these compounds. We tried to answer the question: what drugs give pain relief, or freedom from pain, two hours after intake in oral, subcutaneous or intranasal forms. Then we assigned a strength of recommendation for each drug and a rating for the quality of evidence.

What do the guidelines show?

They show which drugs are effective and which are not, according to today’s data. They contain recommendations both for individual molecules and combination therapies. Different combinations that are not effective enough can lead to development of medication overuse headache, which you always have to be cautious of.

There is also a head-to-head comparisons section, showing what the best options are if we need to switch a patient from one drug to another due to lack of efficacy or side effects.

There is a short summary version [available here] with all the recommendations for prevention and acute treatment. This can basically be used as a practical, concise, evidence-based guidelines that can be easily referred to during practice, which is particularly useful for general neurologists.

What drugs are recommended for acute treatment of migraines?

For headache specialists, the recommendations are perhaps not hugely surprising. The evidence showed that simple analgesics like paracetamol work very well. Paracetamol monotherapy is the gold standard.

The triptans also all showed high efficacy with a strong quality of evidence. There was also some new data on ditans and gepants, and good data on combinations like caffeine with acetylsalicylic acid and paracetamol.

How do you think the guidelines will change clinical practice?

They don’t provide step-by-step recommendations saying start with this drug, then try this, but they do give guidance. So for instance if a patient has nausea, the guidelines state that subcutaneous or intranasal triptans may be a good choice.

Another practical impact will be to hopefully reduce the number of headache medication overuse headaches. When a patient has a headache, whether it’s migraine or tension-type, and they are taking some over-the-counter drug or even prescribed drug, if they don’t have adequate relief then they will continue taking more and more pills.

But we now have more crystallised data to be able to select better molecules for specific patients. I hope that this will lead to fewer cases when the patient will not be happy with the result and will increase the usage and develop medication overuse headache

What are the challenges in migraine treatment that still need to be addressed?

There is still not much available data for special populations so it is hard to draw conclusions for them. A lot of pregnant women and children are having headaches and struggling to cope but we are very limited in our options. Elderly patients as well are a challenge because of their comorbidities.

Another open question is head-to-head comparisons of the drugs. Some have been included in this guideline, but overall the data is limited on how to start and when to switch. So if, for instance, the patient is already taking ibuprofen, should we switch her to paracetamol, or to a tryptan, and if we should then when?

What were some of your highlights from the EAN Congress?

It was good to see the European Migraine & Headache Alliance (EMHA) patient association, which has representatives of patient societies from almost all of the European countries. The group spoke with clinicians so they can distribute the data and insights to other patients in their countries, which is good because peer support is very important.

There was also the migraine-friendly workplace initiative, where the patient associations have encouraged employers to understand that migraine is a debilitating condition that employees should be given sick leave for. Many big companies are recognising this and also creating initiatives like a quiet dark room where people experiencing a migraine can just go to and stay in for some time.