From the Guidelines
Treatment for headaches should prioritize the use of NSAIDs, acetaminophen, or a combination of both for mild episodic migraine headache, while considering CGRP antagonists or ergot alkaloids for moderate to severe cases, as recommended by the most recent guidelines from the American College of Physicians 1. When managing headaches, it's crucial to consider the severity and frequency of the episodes. For mild to moderate headaches, over-the-counter pain relievers such as acetaminophen or ibuprofen can be effective. However, for migraine headaches, more specific treatments like triptans or CGRP antagonists may be necessary.
- Key considerations in treating headaches include:
- The use of NSAIDs (aspirin, celecoxib, diclofenac, ibuprofen, or naproxen) or triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, or zolmitriptan) based on individual patient preferences and factors like route of administration and cost 1.
- Avoiding the use of opioids or butalbital for acute episodic migraine treatment due to potential adverse effects and the risk of medication overuse headache 1.
- Considering nonoral triptans and antiemetics for patients with severe nausea or vomiting 1.
- Discussing the potential adverse effects of pharmacologic treatments during pregnancy and lactation with patients of childbearing potential 1.
- Counseling patients to start treatment as soon as possible after headache onset and using combination therapy to improve efficacy 1.
- Being aware of medication overuse headache, which can occur with the overuse of acute medications, and educating patients on this potential complication 1. Given the most recent and highest quality evidence, the treatment approach should focus on individualized decision-making, considering the patient's specific needs and preferences, and prioritizing the use of evidence-based pharmacologic treatments to improve outcomes and quality of life 1.
From the FDA Drug Label
Before treating headaches in patients not previously diagnosed as migraineurs, and in migraineurs who present with atypical symptoms, exclude other potentially serious neurological conditions. Sumatriptan tablets are contraindicated in patients with a history of stroke or TIA. Rizatriptan benzoate should not be administered to patients with a history of stroke or transient ischemic attack
The treatment options for headaches include:
- Sumatriptan (PO): for patients diagnosed with migraine, after excluding other potentially serious neurological conditions 2
- Rizatriptan (PO): for patients diagnosed with migraine, after excluding other potentially serious neurological conditions 3 Key considerations:
- Exclude other potentially serious neurological conditions before treating headaches
- Contraindicated in patients with a history of stroke or TIA
- Monitor blood pressure in patients treated with sumatriptan or rizatriptan
- Discontinue treatment if a cerebrovascular event or serotonin syndrome occurs
From the Research
Treatment Options for Headaches
- The primary goals of acute migraine therapy are to reduce attack duration and severity 4
- Current evidence-based therapies for acute migraine attacks include:
- Acetaminophen
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Triptans
- NSAID-triptan combinations
- Dihydroergotamine
- Non-opioid combination analgesics
- Anti-emetics 4
- Over-the-counter medications, such as acetaminophen, ibuprofen, naproxen, and aspirin, are considered a first-line therapy for most migraineurs and have shown strong efficacy when used as first-line treatments for mild-to-moderate migraine attacks 4
- Acetaminophen 1000 mg is an effective and well-tolerated treatment for episodic and moderate migraine headache, and provides a beneficial effect on associated symptoms of migraine including nausea, photophobia, phonophobia, and functional disability 5, 6
- High-dose aspirin, in doses from 900 to 1300 mg, taken at the onset of symptoms, is an effective and safe treatment option for acute migraine headaches 7
- Daily aspirin, in doses from 81 to 325 mg, may be an effective and safe treatment option for the prevention of recurrent migraine headaches 7
Migraine Prophylaxis
- Migraine prophylaxis should be implemented when more than 3 attacks occur per month, if attacks do not respond to acute treatment, or if the adverse effects of acute treatment are severe 8
- Substances with proven efficacy for migraine prophylaxis include:
- Beta-blockers (metoprolol and propranolol)
- Calcium antagonist (flunarizine) 8