From the Guidelines
Headaches are classified into primary and secondary types, with primary headaches arising independently and secondary headaches resulting from underlying conditions, and the most effective treatment approach is often based on the specific headache type and underlying pathophysiology, as recommended by the American College of Physicians in their 2025 guideline 1. The most common primary headaches include tension-type headaches, migraines, and cluster headaches.
- Tension-type headaches present with bilateral, pressing pain of mild to moderate intensity, typically without nausea or significant light sensitivity, and are treated with NSAIDs like ibuprofen (400-600mg every 6 hours as needed) or acetaminophen (500-1000mg every 6 hours) 1.
- Migraines cause moderate to severe throbbing pain, often unilateral, with nausea, vomiting, and sensitivity to light and sound, and involve neuronal hyperexcitability, cortical spreading depression, and trigeminovascular activation, with acute treatment including NSAIDs, triptans (sumatriptan 50-100mg orally at onset), and antiemetics, while preventive options include propranolol (40-160mg daily), topiramate (25-100mg daily), and CGRP antagonists, such as atogepant or rimegepant, as recommended by the American College of Physicians in their 2025 guideline 1.
- Cluster headaches cause excruciating unilateral periorbital pain with autonomic symptoms like tearing and nasal congestion, occurring in clusters lasting weeks to months, and involve hypothalamic activation, with treatment including high-flow oxygen (12-15L/min) and triptans, and preventive options like verapamil (240-480mg daily) 1. Secondary headaches require diagnosis and treatment of the underlying cause, which may include medication overuse, sinusitis, intracranial pressure changes, or serious conditions like meningitis, stroke, or tumors, and red flags warranting immediate evaluation include sudden-onset severe headache, neurological deficits, fever, immunocompromise, and onset after age 50, as noted in the 2024 VA/DoD clinical practice guideline for the management of headache 1. The differential diagnosis should consider both primary headache disorders and potential secondary causes based on clinical presentation, with treatment tailored to the specific headache type and underlying pathophysiology, and the American College of Physicians recommends a patient-centered approach, considering individual patient preferences and values, as well as the potential benefits and harms of each treatment option, as outlined in their 2025 guideline 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Types of Headaches
- Primary headache disorders:
- Migraine
- Tension-type headache
- Trigeminal autonomic cephalalgias
- Other primary headache disorders 2
- Secondary headache disorders:
- Vascular causes (e.g. subarachnoid hemorrhage)
- Neoplastic causes
- Infectious causes (e.g. meningitis)
- Intracranial pressure/volume causes 2
Symptoms
- Migraine: often accompanied by sensitivity to light, sound, or smells, and may be preceded by an aura 2
- Tension-type headache: typically described as a band or a squeezing sensation around the forehead, back of the neck, or both 2
- Subarachnoid hemorrhage: often presents with a sudden, severe headache (thunderclap headache), and may be accompanied by neck pain or stiffness, witnessed loss of consciousness, or limited neck flexion on exam 3
- Meningitis: may present with a migraine-like headache, and may be relieved by sumatriptan 4
Pathophysiology
- Subarachnoid hemorrhage: caused by bleeding into the space surrounding the brain, often due to a ruptured aneurysm 5
- Migraine: exact pathophysiology is not fully understood, but is thought to involve changes in blood flow and neurotransmitter activity 2
- Tension-type headache: thought to be related to muscle tension and stress 2
Differential Diagnosis (DDx)
- Subarachnoid hemorrhage: must be considered in patients with sudden, severe headache, especially if accompanied by neck pain or stiffness, witnessed loss of consciousness, or limited neck flexion on exam 3
- Meningitis: must be considered in patients with headache and fever, especially if accompanied by neck stiffness or other signs of infection 4
- Migraine: must be considered in patients with recurrent headaches accompanied by sensitivity to light, sound, or smells, and may be preceded by an aura 2
Treatments
- Acute migraine treatment:
- Acetaminophen
- Nonsteroidal anti-inflammatory drugs
- Combination products that include caffeine
- Triptans (5-HT1B/D agonists)
- Gepants (antagonists to receptors for the inflammatory neuropeptide calcitonin gene-related peptide)
- Lasmiditan (a 5-HT1F agonist) 2
- Preventive treatments for migraine:
- Antihypertensives
- Antiepileptics
- Antidepressants
- Calcitonin gene-related peptide monoclonal antibodies
- OnabotulinumtoxinA 2
- Subarachnoid hemorrhage: treatment typically involves surgical intervention to repair the ruptured aneurysm, and may also include medical management to prevent further bleeding and manage symptoms 5