What medications are recommended for acute headache management?

From the Guidelines

For acute headache management, the most effective approach is to use a combination of medications, starting with NSAIDs or acetaminophen, and adding a triptan if necessary, as recommended by the American College of Physicians in 2025 1.

Key Recommendations

• For mild episodic migraine headache, consider treating with an NSAID, acetaminophen, or the combination of an NSAID and acetaminophen 1.
• If patients do not achieve sufficient pain relief with an NSAID or acetaminophen, consider adding a triptan to an NSAID, or to acetaminophen when NSAIDs are contraindicated or not tolerated 1.
• For moderate to severe acute episodic migraine headache, consider using CGRP antagonists-gepants (rimegepant, ubrogepant, or zavegepant) or ergot alkaloid (dihydroergotamine) in nonpregnant outpatient adults who do not tolerate or have inadequate response to combination therapy of a triptan and an NSAID or acetaminophen 1.

Medication Options

• NSAIDs: ibuprofen (Advil, Motrin) 400-600mg every 6-8 hours or naproxen sodium (Aleve) 440-550mg twice daily 1.
• Acetaminophen: 650-1000mg every 6 hours 1.
• Triptans: sumatriptan (Imitrex) 50-100mg orally or 6mg subcutaneously 1.
• CGRP antagonists-gepants: rimegepant, ubrogepant, or zavegepant 1.

Important Considerations

• Avoid using opioids or butalbital for the treatment of acute episodic migraine 1.
• Consider using a nonoral triptan and an antiemetic in people having severe nausea or vomiting 1.
• Limit the use of acute headache medications to less than 10-15 days per month to avoid medication overuse headaches 1.

From the FDA Drug Label

Sumatriptan tablets, USP are a serotonin (5-HT1B/1D) receptor agonist (triptan) indicated for acute treatment of migraine with or without aura in adults. Sumatriptan tablets are not used to treat other types of headaches such as hemiplegic or basilar migraines. Sumatriptan tablets are not used to prevent or decrease the number of migraine headaches you have.

Recommended Medications for Acute Headache Management:

• Sumatriptan (PO) is recommended for the acute treatment of migraine with or without aura in adults.
• The dosage is a single dose of 25 mg, 50 mg, or 100 mg tablet.
• A second dose should only be considered if some response to the first dose was observed, with at least 2 hours between doses.
• The maximum dose in a 24-hour period is 200 mg.

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From the Research

Recommended Medications for Acute Headache Management

• Acetaminophen (paracetamol) is an effective treatment for acute migraine headaches, with a number needed to treat (NNT) of 12 for 2-hour pain-free and 5.2 and 5.0 for 1- and 2-hour headache relief, respectively 3
• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, diclofenac, ibuprofen, and naproxen are also effective for acute migraine treatment, with a Level A recommendation from the American Headache Society (AHS) 4
• Triptans, such as sumatriptan, are first-line treatments for moderate to severe migraines, with an NNT of 5.2 for 2-hour headache relief 3, 4
• Antiemetics, such as metoclopramide, can be used as supplement to alleviate nausea and vomiting, and can be combined with paracetamol or triptans for improved efficacy 3, 4
• Combination analgesics, such as acetaminophen/aspirin/caffeine, are also effective for acute migraine treatment, with a Level A recommendation from the AHS 4

Treatment Strategies

• A stratified treatment approach is recommended, with mild to moderate migraines treated with oral NSAIDs or acetaminophen, and moderate to severe migraines treated with triptans or ergotamine/caffeine compounds 4, 5
• Early initiation of therapy and adequate dosing at first dose are important principles for acute headache treatment 6
• Careful attention to avoiding too frequent administration of acute therapy is important to avoid medication overuse headaches, with a maximum of 10 days per month recommended 4, 6
• Preventive treatment is indicated for frequent headaches, with low-dose medication and careful titration and monitoring of headache frequency 6

Over-the-Counter Medications

• Over-the-counter (OTC) medications, such as acetaminophen and NSAIDs, are commonly used for headache treatment and can be effective, but patients should be educated about ingredients, efficacy, safety, side effects, and appropriate use 7
• A step-care approach is recommended, starting with simple analgesics and moving to combination products or prescription products as needed 7