Pharmacotherapy for chronic migraine prevention: a narrative review
Abstract
Introduction: Chronic migraine (CM) is a disabling neurological disorder with evolving diagnostic criteria that have influenced how we interpret the evidence base for preventive treatment. Affecting 1-2% of the population, CM imposes substantial individual and societal burden.
Areas covered: This narrative review summarizes the evidence for CM prevention. Literature was identified through PubMed and Google Scholar through April 2026. We review traditional oral preventives, onabotulinumtoxinA, calcitonin gene-related peptide (CGRP)-targeted monoclonal antibodies, gepants, and emerging therapeutic targets, emphasizing CM-specific efficacy, safety, and outcomes in patients with medication overuse and prior treatment failures.
Expert opinion: Although traditional oral preventives remain widely used in CM, most lack CM-specific trial data under current diagnostic criteria and their use largely reflects extrapolation from episodic migraine. Therapies targeting migraine pathophysiology, including CGRP-targeted agents and onabotulinumtoxinA, offer more robust CM-specific evidence, although effect sizes are modest and comparative efficacy data against established oral preventives remain limited. Despite guidelines endorsing CGRP-targeting therapies as first-line, access barriers limit real-world implementation. Incomplete response and the lack of predictive biomarkers, reflecting disease heterogeneity, pose major challenges in CM management. Future progress may lie in strengthening…
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