Preventive goals in migraine care are evolving rapidly. As the historical benchmark of a targeted reduction in monthly migraine days is no longer sufficient, migraine freedom, which addresses both the attacks themselves and the associated interictal burden, should define modern treatment strategies.

We used to separate acute treatment from preventive treatment for migraine. There has been a dramatic change in terms of our goals for migraine prevention treatment due to the advent of migraine-specific preventive therapy. We used to aim for a goal reduction, such as at least a 50% reduction of monthly migraine days. However, in January 2025, the International Headache Society (IHS) published its new goals for preventive treatment, which aim to achieve “migraine freedom.” Now I tell my patients that our goal should be to get to a point where they forget that they have migraine, and I discuss this goal with every patient when initiating prophylactic treatment.

There was a huge recent study called the OVERCOME (US) study. When patients were asked about the most important reason they sought care with a practitioner for their headache, their answers were not migraine frequency, duration, severity, or even related loss of work or disability. What drove patients to seek care was interictal burden. If one thinks about episodic migraine, patients have attacks and may not completely revert to normal between these attacks. There may be effects on cognition, mood, and/or energy. The subtle differences that occur between migraine attacks are profound, and they often motivate patients to see a practitioner.

We also now know from functional imaging studies and clinical trials that for 1 to 3 days before the actual migraine pain begins, there can be functional connectivity changes in the brain that correspond to a prodrome, which then manifests as sensitivity to light, neck symptoms, fatigue, sensitivity to noise, or dizziness. Patients are now taught to pay attention to these prodromal symptoms so that they can predict when the migraine pain is coming. Therefore, when we think of migraine freedom, we are considering what is happening on the headache days as well as what is happening between the headache days. Migraine freedom has to include all of that.

When we are prescribing migraine prevention treatments, we should not require the patient to try nonspecific treatments first, such as tricyclic antidepressants, SNRIs, antiepileptic drugs, or antihypertensives. A 2015 study in more than 8600 individuals with chronic migraine who were put on those medicines found that up to 83% of patients were off their medication by the end of 1 year, which is a 17% adherence rate. Instead of the nonspecific treatments, I now go right to migraine-specific prevention as first-line treatment because of the improved efficacy, tolerability, and safety of these agents, as well as better patient adherence. Eliminating step care with nonspecific medications and matching patient needs to treatment with migraine-specific therapy were both recommended in the 2024 American Headache Society (AHS) position statement update.

I will typically discuss with the patient what their preferences are (eg, oral vs injectable and daily vs every other day, monthly, or quarterly), and we will go from there. I have not seen strong evidence that one particular medication is superior for migraine prevention vs another. If a patient experiences only partial benefit from one therapy, I usually do not substitute it with another therapy. Instead, I combine it with another therapy that works differently, because I am trying to get patients not only to improvement but also to migraine freedom.