What are the recommendations for managing a headache?

From the Guidelines

For a headache, I recommend starting with a triptan and an NSAID or acetaminophen, as this combination has been shown to be effective in treating acute episodic migraine headache in outpatient settings 1. When treating headache, it's essential to consider the severity and frequency of the episodes.

• For moderate to severe acute episodic migraine headache, consider using the ditan lasmiditan in nonpregnant outpatient adults who do not tolerate or have inadequate response to all other pharmacologic treatments included in the guideline 1.
• Avoid using opioids or butalbital for the treatment of acute episodic migraine, as they can have adverse effects and are not recommended by current guidelines 1.
• For people with severe nausea or vomiting, consider using a nonoral triptan and an antiemetic to improve treatment outcomes 1.
• It's crucial to counsel patients to begin treatment of migraine headache as soon as possible after its onset, using combination therapy to improve efficacy, and to be aware of medication overuse headache, which can be a potential complication of migraine treatment 1.
• Lifestyle modifications, such as staying well hydrated, maintaining regular meals, securing sufficient and consistent sleep, engaging in regular physical activity, managing stress, and pursuing weight loss if applicable, can also help alleviate headache symptoms 1.
• If the episodic migraine occurs frequently or treatment does not provide an adequate response, consider adding preventive medications, such as beta blockers, topiramate, or candesartan, as first-line medications, or CGRP monoclonal antibodies as third-line medications 1.

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 The results from the 3 controlled clinical trials are summarized in Table 2. Table 2 Percentage of Patients With Headache Response (Mild or No Headache) 2 and 4 Hours Following Treatment Sumatriptan Tablets 25 mg 2 hr 4 hr Sumatriptan Tablets 50 mg 2 hr 4 hr Sumatriptan Tablets 100 mg 2 hr 4 hr Placebo 2 hr 4 hr

Recommendation for Headache: Sumatriptan tablets are effective in the acute treatment of migraine headaches. The recommended dose is 25,50, or 100 mg, with 50 and 100 mg doses showing a statistically significant greater percentage of patients with headache response at 2 and 4 hours in one of the trials.

• Key Points:
  • Sumatriptan tablets are effective for migraine headaches
  • Doses of 25,50, and 100 mg are compared with placebo
  • 50 and 100 mg doses show greater efficacy in one trial 2

From the Research

Treatment Options for Headache

• Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line treatments for mild to moderate migraines 3, 4, 5, 6
• Triptans are first-line treatments for moderate to severe migraines, but may be expensive 3, 4, 5, 6
• Antiemetics, ergot alkaloids, and combination analgesics have evidence supporting their effectiveness in the treatment of migraine 5, 6
• Gepants, antagonists to receptors for the inflammatory neuropeptide calcitonin gene-related peptide, can eliminate headache symptoms for 2 hours in 20% of patients 4
• A 5-HT1F agonist, lasmiditan, is also available for acute migraine treatment and appears safe in patients with cardiovascular risk factors 4

Considerations for Specific Patient Groups

• For children and adolescents, paracetamol (acetaminophen) and ibuprofen can be recommended for the acute treatment of migraine attacks 7
• Sumatriptan nasal spray can be recommended for adolescents, but the oral formulation has not shown efficacy in pediatric patients 7
• For patients with contraindications to vasoconstricting drugs, NSAIDs, combination analgesics, and dopamine antagonists may be used 6
• Acetaminophen is the safest acute migraine drug during pregnancy, and acetaminophen with codeine is also an option 6
• Sumatriptan may be an option during pregnancy for selected patients and is compatible with breast-feeding 6

Treatment Strategies

• The acetaminophen-NSAID strategy is suitable for patients with attacks of mild to moderate severity 6
• The triptan strategy is suitable for patients with severe attacks and for those with attacks of moderate severity who do not respond well to NSAIDs 6
• Refractory migraine strategies may be useful for patients who do not respond well to NSAIDs or triptans alone, and include using triptans and NSAIDs simultaneously in combination, dihydroergotamine, and rescue medications 6