What is the initial approach for inpatient headache treatment?

From the Guidelines

The initial approach for inpatient headache treatment should prioritize non-opioid analgesics, such as intravenous NSAIDs, and consider the use of triptans for migraine-specific treatment, as recommended by the most recent guidelines 1. When managing inpatient headaches, it's crucial to address dehydration, pain, and underlying causes simultaneously.

• Start with intravenous fluids to correct dehydration, which can exacerbate headaches.
• For pain management, begin with non-opioid analgesics such as intravenous ketorolac (30mg IV every 6 hours, maximum 5 days) or acetaminophen (1000mg IV every 6 hours), as these are effective and have a lower risk of medication overuse headache compared to opioids.
• Antiemetics like metoclopramide (10mg IV every 6 hours) or prochlorperazine (10mg IV every 6-8 hours) can help manage associated nausea while also providing some pain relief, as suggested by guidelines for managing migraine 1.
• For migraine-specific treatment, consider sumatriptan (6mg subcutaneous, may repeat once after 1 hour) if there are no cardiovascular contraindications, or dihydroergotamine (0.5-1mg IV every 8 hours), as these are effective for acute migraine treatment 1.
• Avoid opioids when possible, as they can lead to medication overuse headache and dependence, emphasizing the importance of alternative pain management strategies.
• Simultaneously, conduct a thorough evaluation to identify and treat underlying causes such as infection, hypertension, or medication withdrawal.
• Maintain a quiet, dark environment for the patient, as sensory stimulation often worsens headaches. This approach is supported by the latest clinical guideline from the American College of Physicians, which recommends the use of triptans added to nonsteroidal anti-inflammatory drugs for treating moderate to severe acute episodic migraine headache in outpatient settings, and can be adapted for inpatient care 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 controlled clinical trials, single doses of 25,50, or 100 mg of sumatriptan succinate tablets were effective for the acute treatment of migraine in adults.

The initial approach for inpatient headache treatment is to administer sumatriptan at a dose of 25, 50, or 100 mg.

• The choice of dose should be made on an individual basis, weighing the possible benefit of a higher dose with the potential for a greater risk of adverse events.
• If the headache returns or the patient has a partial response to the initial dose, the dose may be repeated after 2 hours, not to exceed a total daily dose of 200 mg 2, 3.

From the Research

Initial Approach to Inpatient Headache Treatment

The initial approach to inpatient headache treatment involves a thorough and systematic evaluation to determine the underlying cause of the headache.

• A complete neurological examination is essential in the diagnosis of both primary and secondary headache disorders 4.
• Consideration of neuroimaging, serum, or spinal fluid analysis may be necessary in specific situations to rule out potentially fatal headache syndromes 4.
• A diagnostic approach to headache ensures that resource-intensive tests are performed only on an as-needed basis, while not overlooking critical conditions 4.

Diagnostic Considerations

When evaluating a patient with headache, it is crucial to determine whether the headache is a primary or secondary headache disorder.

• Primary headache disorders, such as migraine and tension-type headache, are unrelated to an underlying medical condition 5.
• Secondary headache disorders are caused by an underlying medical condition, such as vascular, neoplastic, infectious, or intracranial pressure/volume causes 5.
• Patients presenting with headache should be evaluated for symptoms or signs that suggest an urgent medical problem, such as abrupt onset, neurologic signs, or age 50 years and older 5.

Treatment Options

The treatment of headache depends on the underlying cause and may involve acute and preventive therapies.

• Acute migraine treatment includes acetaminophen, nonsteroidal anti-inflammatory drugs, and combination products that include caffeine 5.
• Migraine-specific treatments, such as triptans, gepants, and lasmiditan, may be necessary for patients who do not respond to initial treatments 5, 6.
• Preventive treatments, including antihypertensives, antiepileptics, antidepressants, and calcitonin gene-related peptide monoclonal antibodies, may be indicated for frequent headaches 5, 7.