Migraine affects roughly 39 million Americans, about one in eight, making it one of the most common conditions in any patient population. It also resists the kind of clean treatment sequencing seen in other chronic conditions.
One patient fills a preventive medication only a few times a year, even though it was prescribed to reduce frequency. Another relies on a rescue treatment monthly without ever having tried prevention. A third uses both, consistently, because for some patients stability isn't found in a textbook sequence of care, it's found in the specific combination that keeps the next attack from taking over the week. All three patterns can be clinically appropriate. None of them follow a predictable, linear path the way hypertension or diabetes management often does.
In 2024, the American Headache Society elevated CGRP medications, calcitonin gene-related peptide inhibitors, to first-line treatment for chronic migraine, a meaningful shift from their prior role as later-line therapy after other options had failed. Prescribing patterns moved quickly in response: across one year of utilization data, CGRP use rose 20% among patients, with individual products like Ubrelvy® and Emgality® seeing utilization increases of 80.1% and 62.8% respectively.
That individualization has practical implications at the point of prescribing. Because preventive and rescue therapies can serve different roles for different patients, a regimen that looks irregular on review, infrequent preventive fills paired with frequent rescue use, for example, may not indicate undertreatment or nonadherence. It may reflect a patient who has found what actually controls their migraines, even if it doesn't match the expected sequence.
Clinical takeaway: when reviewing a migraine regimen that doesn't follow the standard prevention-first sequence, consider whether the irregularity reflects a patient-specific pattern that's working before assuming it represents a gap in care. The shift of CGRPs to first-line status means more patients will present with regimens built around what controls their migraines specifically, not around a single expected pathway.
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