A year of milestones in headache: Highlights from <i>Cephalalgia</i> 2025

The aim of this editorial is to bring to the attention of Headache readers and the American Headache Society community a selection of papers recently published in 2025 in Cephalalgia, the official journal of the International Headache Society (IHS). This initiative reflects the shared mission and spirit of collaboration between the IHS and American Headache Society, both dedicated to advancing science, improving care for people with headache disorders, and fostering global dialogue within our field. The progress of headache medicine depends on open exchange and reciprocal visibility between our communities. The past year has been an extraordinary one for the field of headache medicine. The papers published in Cephalalgia in 2025 reflect a community that is active, creative, and increasingly collaborative—one that is forward-looking and committed to setting ever higher standards in science and clinical care. Among the most remarkable publications from 2025 in Cephalalgia is “Evidence-Based Guidelines for the Pharmacological Treatment of Migraine,” developed through a joint effort of the IHS and the Italian Society for the Study of Headache.1 These are the first evidence-based, comprehensive guidelines covering all available pharmacological agents for acute attack treatment and for the prevention of migraine attacks. They represent a new benchmark for evidence-based practice and will serve as a reference for clinicians and policymakers alike. The simultaneous publication of a concise summary version ensures that the recommendations are easily accessible and practical, facilitating their application in everyday clinical decision-making.2 Innovation in pharmacological therapy was also represented by the PRECLUDE trial—a rigorous, multicenter, phase 3 study evaluating the efficacy and safety of onabotulinumtoxinA in episodic migraine.3 The study confirmed that onabotulinumtoxinA was well tolerated but did not show significant efficacy versus placebo for reducing monthly migraine days from baseline in patients with episodic migraine. Although the drug remains effective for chronic migraine, these findings highlight the need for further research to better understand the pathophysiological differences between episodic and chronic migraine, and to determine whether specific subgroups of patients with episodic migraine may benefit from this treatment. A second evidence-based guideline published by the IHS focused on noninvasive neuromodulation devices for the acute and preventive treatment of migraine.4 This comprehensive synthesis of evidence positions neuromodulation as a validated and promising component of modern migraine care. This is a true milestone, as no formal guidance on the use of such devices was previously available, despite their increasing presence in the market and the pressing need for clinicians and regulatory authorities to rely on clear, evidence-based recommendations. The emphasis on methodological rigor and transparency runs through many of this year's publications. The “Guidelines of the International Headache Society for Real-World Evidence Studies in Migraine and Cluster Headache”5 provide essential direction for designing, conducting, and reporting observational research. In an era where real-world data are increasingly central to understanding treatment effectiveness and patient experience, these guidelines come at exactly the right time to ensure the reliability and comparability of real-world studies. The advent of calcitonin gene-related peptide pathway-targeting treatments has transformed the landscape of migraine management and prompted a broader reflection on how the disease should be approached. Two position papers from the IHS published in 2025 address this shift. The first6 calls for setting higher standards for migraine prevention, advocating for treatment strategies that go beyond mere attack control to achieve meaningful, sustained improvement in patients' quality of life. The paper emphasizes the need to target residual migraine burden and to strive for complete or near-complete disease control, ideally reducing moderate-to-severe headache days to 4 or fewer per month. The second position paper7 calls for a shift in prevention from attacks to disease progression. Untreated or undertreated migraine can progress over time, leading to cumulative disability and poorer outcomes. Early and proactive treatment may modify this trajectory. Although this concept must still be confirmed through pragmatic clinical trials, it offers a new and hopeful vision of how migraine should be managed. Together, these statements signal a profound change in how we conceptualize migraine—not as a series of isolated episodes, but as a chronic neurological disorder that demands meaningful, early, and sustained interventions. The importance of clear definitions and shared language was underscored by the international consensus on the definition of refractory migraine, achieved through a Delphi process.8 This paper advances our ability to define and study difficult-to-treat migraine and provides a foundation for future research and advocacy. Establishing common terminology is essential if we are to develop better diagnostic, therapeutic, and policy frameworks for these patients. This year also marked important progress in the care of younger patients. A collaborative work by the IHS Child and Adolescent Committee addressed a crucial but often neglected topic: the transition of headache care from childhood to adulthood.9 Their position paper identifies key needs and barriers and proposes models of care to ensure that young people with headache receive continuous and developmentally appropriate management—a call to action that resonates deeply with clinicians, families, and policymakers. Finally, a masterful contribution by Professor Jes Olesen—the father of the International Classification of Headache Disorders (ICHD)—revisited how we can further advance one of the cornerstones of our field, the headache classification.10 The ICHD has evolved significantly from edition to edition, but much remains to be explored even after ICHD-3. Professor Olesen's reflection on past achievements, methodological challenges, and future directions reminds us that progress in research and clinical care is inseparable from conceptual clarity and diagnostic precision. Taken together, these 10 articles signify advances but also remind us about the remaining unmet needs in our field. They reveal a discipline that is maturing scientifically, uniting methodology with meaning, and working collectively to improve the lives of people living with headache. The pace of progress in headache research has never been faster. Simona Sacco: Conceptualization; writing – original draft; writing – review and editing. Simona Sacco reports personal fees as speaker or advisor from Abbott, Allergan-AbbVie, AstraZeneca, Bayer, Boheringer, Eli Lilly, Lundbeck, Pfizer, and Teva; research grants from Novartis and Uriach; royalties from, Abbott, Allergan-AbbVie, AstraZeneca, Boheringer, Eli Lilly, Lundbeck, Novartis, NovoNordisk, Pfizer, and Teva; consulting fees from Abbott, Allergan-AbbVie, AstraZeneca, Boheringer, Eli Lilly, Lundbeck, MedScape, Novartis, NovoNordisk, Pfizer, and Teva; expert testimony for Abbott, Allergan-AbbVie, AstraZeneca, Boheringer, Eli Lilly, Lundbeck, Novartis, NovoNordisk, Pfizer, Teva, Bayer, Medtronic, Starmed, Bristol-Myers-Squibb, and Daiichi-Sankyo; patents for Allergan-AbbVie, AstraZeneca, Eli Lilly, Lundbeck, Novartis, Pfizer, and Teva. Simona Sacco is President-Elect of the European Stroke Organization, Editor-in-Chief of Cephalalgia and Cephalalgia Reports, and an assistant editor for Stroke.