What are the recommended treatments for headache management?

From the Guidelines

Headache management should begin with over-the-counter pain relievers such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen sodium, as recommended by the most recent guideline from the American College of Physicians 1.

First-Line Treatment

• For mild episodic migraine headache, consider treating with an NSAID, acetaminophen, or the combination of an NSAID and acetaminophen 1.
• The choice of a specific NSAID (aspirin, celecoxib, diclofenac, ibuprofen, or naproxen) or triptan (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, or zolmitriptan) should be based on individualized decision making, taking into consideration patient preferences on such factors as route of administration and cost 1.

Migraine-Specific Agents

• For patients whose migraine attack has not responded to NSAIDs, use migraine-specific agents (triptans, DHE) 1.
• Consider using a nonoral triptan and an antiemetic in people having severe nausea or vomiting 1.

Preventive Therapy

• Migraine sufferers should be evaluated for use of preventive therapy, with recommended first-line agents including propranolol, timolol, amitriptyline, divalproex sodium, and sodium valproate 1.
• Consider using preventive medications such as propranolol, topiramate, or amitriptyline for frequent episodes of migraine 1.

Lifestyle Modifications

• Highlight the importance of lifestyle modifications with patients, including staying well hydrated, maintaining regular meals, securing sufficient and consistent sleep, engaging in regular physical activity, managing stress with relaxation techniques or mindfulness practices, and, where applicable, pursuing weight loss for those who are overweight or obese 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 trials, doses of 25,50, and 100 mg were compared with placebo in the treatment of migraine attacks. 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 recommended treatments for headache management include sumatriptan tablets at doses of 25 mg, 50 mg, or 100 mg.

• These doses have been shown to be effective in the acute treatment of migraine headaches.
• The treatment can be repeated after 4 to 24 hours if the headache recurs.
• Additionally, acetaminophen can be offered to patients if the migraine pain has not improved or worsened after 2 hours of initial treatment 2.

From the Research

Headache Management Treatments

• The following treatments are recommended for headache management:
  • Acetaminophen (paracetamol) alone or in combination with an antiemetic for acute migraine headaches in adults 3
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, and aspirin for mild to moderate migraines 4, 5, 6, 7
  • Triptans, such as sumatriptan, for moderate to severe migraines 3, 4, 6, 7
  • Antiemetics, such as metoclopramide, to reduce nausea and vomiting associated with migraine 3
  • Combination products that include caffeine for acute migraine treatment 6
  • Gepants, antagonists to receptors for the inflammatory neuropeptide calcitonin gene-related peptide, such as rimegepant or ubrogepant, for acute migraine treatment 6
  • Lasmiditan, a 5-HT1F agonist, for acute migraine treatment 6
• The choice of treatment should be based on the severity of the migraine, the presence of nausea and vomiting, and the patient's medical history and preferences 4, 7
• A stratified treatment approach, where treatment is tailored to the individual patient's needs, is recommended 4, 7
• Preventive treatments, such as antihypertensives, antiepileptics, antidepressants, calcitonin gene-related peptide monoclonal antibodies, and onabotulinumtoxinA, may be considered for patients with frequent or severe migraines 6

Treatment Guidelines

• The American Headache Society (AHS) and the Taiwan Headache Society have published treatment guidelines for acute migraine attacks 7
• The guidelines recommend a step-wise approach to treatment, with mild to moderate migraines treated with oral NSAIDs or acetaminophen, and moderate to severe migraines treated with triptans or ergotamine/caffeine compounds 7
• The use of acute treatment should be limited to a maximum of ten days a month to prevent medication-overuse headache 7