What are the treatment options for headaches and management of adverse effects of headache medications?

From the Guidelines

For treating headaches, start with over-the-counter medications like ibuprofen (Advil, Motrin) 400-600mg every 6-8 hours as needed, as recommended by the most recent guidelines 1.

Key Considerations

• Stay hydrated, rest in a dark quiet room, and apply cold or warm compresses to your head or neck.
• For medication side effects, NSAIDs like ibuprofen may cause stomach irritation, so take with food and avoid if you have kidney problems or stomach ulcers.
• If you experience nausea from these medications, take them with food or try ginger tea.
• For drowsiness from some headache medications, avoid driving or operating machinery.
• If headaches are severe, persistent, or accompanied by fever, vision changes, or neck stiffness, seek medical attention immediately as these could indicate serious conditions.

Preventive Treatments

• Consider a headache diary to identify triggers and consult a healthcare provider about preventive treatments like amitriptyline, propranolol, or topiramate, especially if you have frequent or disabling headaches 1.
• Discuss with your healthcare provider the evidence for and side effects of these medications, as well as the potential benefits and risks of preventive therapy.

Management of Adverse Effects

• Acetaminophen can cause liver damage with overuse or alcohol consumption, so don't exceed 3000mg daily.
• NSAIDs like ibuprofen may cause stomach irritation, so take with food and avoid if you have kidney problems or stomach ulcers.
• If you experience nausea or vomiting, consider taking a non-oral triptan or adding an anti-emetic, as recommended by recent guidelines 1.

From the FDA Drug Label

Sumatriptan tablets are contraindicated in patients with Wolff-Parkinson-White syndrome or arrhythmias associated with other cardiac accessory conduction pathway disorders. The use of sumatriptan tablets is contraindicated in patients with CAD and those with Prinzmetal’s variant angina. Cerebral hemorrhage, subarachnoid hemorrhage, and stroke have occurred in patients treated with 5-HT1 agonists, and some have resulted in fatalities Sumatriptan tablets may cause non-coronary vasospastic reactions, such as peripheral vascular ischemia, gastrointestinal vascular ischemia and infarction Overuse of acute migraine drugs (e.g., ergotamine, triptans, opioids, or combination of these drugs for 10 or more days per month) may lead to exacerbation of headache (medication overuse headache). Serotonin syndrome may occur with sumatriptan tablets, particularly during co-­administration with selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and MAO inhibitors Significant elevation in blood pressure, including hypertensive crisis with acute impairment of organ systems, has been reported on rare occasions in patients treated with 5-HT1 agonists, including patients without a history of hypertension. Anaphylactic/anaphylactoid reactions have occurred in patients receiving sumatriptan. Seizures have been reported following administration of sumatriptan.

The treatment options for headaches include sumatriptan tablets. However, the management of adverse effects of headache medications, such as sumatriptan, is crucial.

• Contraindications: Sumatriptan is contraindicated in patients with certain cardiac conditions, CAD, Prinzmetal’s variant angina, and history of stroke or TIA.
• Serious adverse effects: Cerebral hemorrhage, stroke, non-coronary vasospastic reactions, serotonin syndrome, significant elevation in blood pressure, anaphylactic reactions, and seizures have been reported.
• Medication overuse headache: Overuse of acute migraine drugs, including sumatriptan, may lead to exacerbation of headache. To manage adverse effects, it is essential to:

• Monitor blood pressure in patients treated with sumatriptan.
• Rule out a vasospastic reaction before receiving additional sumatriptan tablets.
• Discontinue sumatriptan tablets if a cerebrovascular event, serotonin syndrome, or anaphylactic reaction occurs.
• Use sumatriptan tablets with caution in patients with a history of epilepsy or conditions associated with a lowered seizure threshold.
• Detoxification of patients, including withdrawal of the overused drugs, and treatment of withdrawal symptoms may be necessary for medication overuse headache 2.

From the Research

Treatment Options for Headaches

• Aspirin 1000 mg is an effective treatment for acute migraine headaches, similar to sumatriptan 50 mg or 100 mg 3
• Addition of metoclopramide 10 mg improves relief of nausea and vomiting 3
• Over-the-counter medications such as acetaminophen, ibuprofen, naproxen, and aspirin have shown strong efficacy when used as first-line treatments for mild-to-moderate migraine attacks 4
• Diclofenac potassium 50 mg is an effective treatment for acute migraine, providing relief from pain and associated symptoms 5
• Sumatriptan is a potent and selective agonist at the vascular 5HT1 receptor, which mediates constriction of certain large cranial blood vessels and/or inhibits the release of vasoactive neuropeptides from perivascular trigeminal axons in the dura mater following activation of the trigeminovascular system 6

Management of Adverse Effects

• Adverse events associated with aspirin are mostly mild and transient, occurring slightly more often with aspirin than placebo 3
• Adverse events associated with diclofenac are mostly mild and transient, occurring at the same rate as with placebo 5
• Sumatriptan is generally well tolerated, and most adverse events are transient, including nausea, vomiting, malaise, fatigue, and dizziness 6
• Chest symptoms are reported in 3 to 5% of patients taking sumatriptan, but have been associated with myocardial ischaemia only in rare isolated cases 6

Preventive Therapy

• Preventive medication therapy reduces migraine frequency, severity, and headache-related distress 7
• First-line medications established as effective based on clinical evidence include divalproex, topiramate, metoprolol, propranolol, and timolol 7
• Complementary treatments such as petasites, feverfew, magnesium, and riboflavin are probably effective in preventing migraines 7
• Nonpharmacologic therapies such as relaxation training, thermal biofeedback combined with relaxation training, electromyographic feedback, and cognitive behavior therapy also have good evidence to support their use in migraine prevention 7