What medications are recommended for headache management?

From the Guidelines

For headache management, the most effective approach is to use a combination of nonsteroidal anti-inflammatory drugs (NSAIDs) and triptans, with consideration of adding CGRP antagonists or ditans for moderate to severe acute episodic migraine headache, as recommended by the American College of Physicians in 2025 1.

Key Recommendations:

• Use NSAIDs such as ibuprofen (Advil, Motrin) at 200-400mg every 4-6 hours or naproxen sodium (Aleve) at 220-440mg every 8-12 hours as first-line treatments for mild episodic migraine headache.
• Add a triptan to an NSAID or acetaminophen for patients who do not achieve sufficient pain relief with NSAIDs or acetaminophen alone.
• Consider using CGRP antagonists (gepants) or ditans for moderate to severe acute episodic migraine headache in nonpregnant outpatient adults who do not tolerate or have inadequate response to other pharmacologic treatments.
• Avoid using opioids or butalbital for the treatment of acute episodic migraine.

Lifestyle Modifications:

• Stay well hydrated by drinking plenty of water.
• Maintain regular meals to prevent hypoglycemia.
• Secure sufficient and consistent sleep to help regulate pain.
• Engage in regular physical activity, such as moderate to intense aerobic exercise, to reduce stress and improve overall health.
• Manage stress with relaxation techniques or mindfulness practices.

Preventive Medications:

• Consider adding preventive medications if episodic migraine occurs frequently or treatment does not provide an adequate response.
• Use beta blockers, topiramate, or candesartan as first-line medications for preventive treatment.
• Consider CGRP monoclonal antibodies as third-line medications for preventive treatment. It's essential to consult a healthcare provider to determine the best course of treatment for individual patients, as they can help develop a personalized plan that takes into account the patient's medical history, lifestyle, and preferences 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 Acetaminophen was offered to patients in Trials 2 and 3 beginning at 2 hours after initial treatment if the migraine pain had not improved or worsened Additional medications were allowed 4 to 24 hours after the initial treatment for recurrent headache or as rescue in all 3 trials.

Recommended medications for headache management include:

• Sumatriptan tablets
• Acetaminophen

These medications have been shown to be effective in the treatment of migraine headaches 2. However, it is essential to note that sumatriptan tablets are contraindicated in certain patients, such as those with CAD, Prinzmetal’s variant angina, or a history of stroke or TIA 2.

From the Research

Headache Medication

• The following medications are recommended for headache management:
  • Acetaminophen (paracetamol) alone or in combination with an antiemetic 3
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, diclofenac, ibuprofen, and naproxen 4, 5
  • Triptans, such as sumatriptan, which are effective for moderate to severe migraines 4, 5, 6, 7
  • Combination products that include caffeine 6, 7
  • Antiemetics, which can be used as supplement to alleviate nausea and vomiting 4, 7
  • Ergot alkaloids, which are recommended for use as second- or third-line therapy for select patients or for those with refractory migraine 7
  • Gepants, such as rimegepant or ubrogepant, which can eliminate headache symptoms for 2 hours in 20% of patients 6
  • Lasmiditan, a 5-HT1F agonist, which appears safe in patients with cardiovascular risk factors 6

Treatment Strategies

• A stratified treatment approach is recommended, where medication is chosen based on the severity of the migraine attack 4, 7
• For mild to moderate migraines, oral NSAIDs are the first choice, with oral aspirin, combination analgesics, and intravenous/intramuscular NSAIDs as alternatives 4
• For moderate to severe attacks, oral or nasal spray triptans and ergotamine/caffeine compounds are recommended, and should be administered in the early stage of migraine attacks 4, 7
• Parenteral steroid and fluid supply are the first choice in treatment of status migrainosus 4
• Acetaminophen is suitable for mild to moderate migraine attacks and remains the first choice for children and pregnant women 4, 6

Important Considerations

• The use of acute treatment should be limited to a maximum of ten days a month to prevent medication-overuse headache 4
• Patients with or at high risk for cardiovascular disease should avoid triptans because of vasoconstrictive properties 6
• Adverse event rates should be considered when choosing a medication, with some medications having a higher risk of adverse events than others 3, 6, 7