What is the treatment for acute headache (cephalalgia)?

From the Guidelines

For acute cefalea treatment, start with over-the-counter analgesics like acetaminophen or NSAIDs such as ibuprofen or naproxen, and consider adding a triptan if insufficient pain relief is achieved, as recommended by the American College of Physicians 1. When treating acute episodic migraine headache, it is essential to ensure that patients are using the appropriate dosage of NSAIDs or acetaminophen, and consider increasing the dosage without exceeding the recommended maximum daily dose if sufficient pain relief is not achieved 1. Some key points to consider in the treatment of acute cefalea include:

• Using NSAIDs, acetaminophen, or the combination of an NSAID and acetaminophen for mild episodic migraine headache 1
• Adding a triptan to an NSAID or acetaminophen if patients do not achieve sufficient pain relief with an adequate dose of an NSAID or acetaminophen alone 1
• Considering the use of CGRP antagonists-gepants or ergot alkaloid for moderate to severe acute episodic migraine headache in nonpregnant outpatient adults who do not tolerate or have inadequate response to combination therapy of a triptan and an NSAID or acetaminophen 1
• Avoiding the use of opioids or butalbital for the treatment of acute episodic migraine 1 It is also important to note that the choice of a specific NSAID or triptan should be based on individualized decision making, taking into consideration patient preferences and factors such as route of administration and cost 1. In contrast to older guidelines, such as those from 2003 1, the most recent recommendations from the American College of Physicians 1 provide a more comprehensive and up-to-date approach to the treatment of acute cefalea.

From the FDA Drug Label

The efficacy of sumatriptan tablets in the acute treatment of migraine headaches was demonstrated in 3, randomized, double-blind, placebo-controlled trials. In all 3 trials, the percentage of patients achieving headache response 2 and 4 hours after treatment was significantly greater among patients receiving sumatriptan tablets at all doses compared with those who received placebo

Acute cefalea treatment with sumatriptan (PO) is effective.

• The medication has been shown to be effective in reducing headache severity from moderate or severe pain to mild or no pain.
• Key findings include:
  • Significant improvement in headache response at 2 and 4 hours after treatment compared to placebo.
  • Reduction in associated symptoms such as nausea, photophobia, and phonophobia. 2

From the Research

Acute Cefalea Treatment

• Acute cefalea, or migraine, treatment includes various medications such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), triptans, and combination products 3, 4, 5.
• For mild to moderate migraines, acetaminophen and NSAIDs are recommended as first-line treatments, while triptans are recommended for moderate to severe migraines 3, 4.
• The American Headache Society (AHS) guidelines recommend triptans, acetaminophen, and NSAIDs as effective treatments for acute migraine attacks, with a Level A recommendation 4.
• Other medications such as dihydroergotamine, antiemetics, and ergot alkaloids may be used as second- or third-line therapy for select patients or for those with refractory migraine 3, 4.

Treatment Principles

• Early initiation of therapy and adequate dosing at first dose are important principles in the acute treatment of headache 6.
• Careful attention to avoiding too frequent administration of acute therapy is important to avoid medication overuse headaches 6.
• A stratified treatment approach, where treatment is individualized based on the pattern and severity of attacks, can help ensure that migraine treatment is cost-effective 3, 4.

Specific Treatments

• Triptans, such as sumatriptan, are effective for acute migraine treatment, but may be expensive and have adverse effects such as transient flushing, tightness, or tingling in the upper body 3, 4, 5.
• Gepants, such as rimegepant or ubrogepant, are also available for acute migraine treatment and have adverse effects of nausea and dry mouth 5.
• Lasmiditan, a 5-HT1F agonist, is also available for acute migraine treatment and appears safe in patients with cardiovascular risk factors 5.
• Antiemetics can be used as supplement to alleviate nausea and vomiting, and parenteral steroid and fluid supply are recommended for treatment of status migrainosus 4.