Advances in primary headache disorder management: A review of pharmacological and non-pharmacological strategies with emphasis on European evidence
Abstract
Primary headache disorders – migraine, tension-type headache, and cluster headache – represented one of the leading causes of years lived with disability worldwide, imposing a substantial socioeconomic burden across Europe, with annual costs estimated in billions of euros owing to lost productivity and increased healthcare utilisation. The aim of research was to critically evaluate evidence on pharmacological and non-pharmacological management of primary headache disorders published between 2019 and 2024, with a specific focus on European clinical data and guideline recommendations, in order to provide practitioners with an immediately applicable, evidence-based update. CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) demonstrated ≥ 50% responder rates of 40-60% and mean reductions of 3-8 monthly migraine days, with real-world European registry persistence exceeding 70% at 12 months – substantially outperforming traditional oral preventives. Oral gepants (atogepant for prevention; rimegepant for acute and preventive use) offered effective, cardiovascular-safe alternatives supported by both pivotal trials and European real-world cohorts. For cluster headache, high-flow oxygen (≥ 12 L/min) and subcutaneous sumatriptan 6 mg remained gold-standard acute treatments, while galcanezumab was the only biologic with strong evidence for episodic cluster headache prevention. Non-pharmacological interventions – cognitive behavioural therapy, biofeedback,…
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