What is the stepwise approach to managing headaches?

Headache Management Algorithm

The most effective approach to managing headaches is a stepped care approach based on headache type, severity, and response to treatment, with NSAIDs as first-line therapy for mild to moderate migraine attacks and combination therapy with triptans for moderate to severe attacks. 1

Step 1: Diagnosis and Classification

• Identify headache type (migraine vs. tension vs. secondary headache)
• Look for red flags that suggest secondary headache:
  • Thunderclap headache (subarachnoid hemorrhage)
  • Headache onset after age 50 (temporal arteritis, tumor)
  • Systemic symptoms (fever, weight loss)
  • Neurological deficits or altered mental status
  • New onset headache in patient with cancer or HIV

Step 2: Acute Treatment of Migraine

First-Line Treatment

• Mild to Moderate Migraine:
  • NSAIDs (strongest evidence for acetylsalicylic acid, ibuprofen, diclofenac potassium) 1
  • Add antiemetic if nausea/vomiting present
  • Acetaminophen only if NSAIDs contraindicated (less efficacious) 1, 2

Second-Line Treatment

• If inadequate response to NSAIDs after three consecutive attacks:
  • Add a triptan (sumatriptan, rizatriptan, etc.) 1
  • Triptans most effective when taken early in attack while pain is mild 1
  • If one triptan ineffective, try another (different triptans have different efficacy profiles) 1

Third-Line Treatment

• If all triptans fail after adequate trial (three consecutive attacks):
  • Consider ditans (lasmiditan) or gepants (rimegepant, ubrogepant) 1
  • Note: These newer medications have limited availability and higher cost

Special Considerations

• For rapid onset or severe nausea/vomiting:
  • Consider sumatriptan subcutaneous injection 1
  • Non-oral formulations (nasal sprays, injections) for those who cannot take oral medications

Step 3: Preventive Treatment

Consider preventive treatment when:

• Migraine occurs ≥2 days per month with disability despite optimized acute treatment 1
• Attacks are particularly severe or prolonged
• Acute medications contraindicated or causing adverse effects
• Risk of medication overuse headache

First-Line Preventive Medications

• Beta blockers (atenolol, bisoprolol, metoprolol, propranolol) 1
• Topiramate 1
• Candesartan 1

Second-Line Preventive Medications

• Flunarizine 1
• Amitriptyline 1
• Sodium valproate (contraindicated in women of childbearing potential) 1

Third-Line Preventive Medications

• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) 1

Step 4: Non-Pharmacological Approaches

• Evidence-supported options:

  • Non-invasive neuromodulatory devices 1
  • Biobehavioral therapy 1
  • Acupuncture 1

• Limited evidence for:

  • Physical therapy
  • Spinal manipulation
  • Dietary approaches

Common Pitfalls and Caveats

1. Medication overuse headache: Avoid using acute medications more than 10-15 days per month to prevent medication overuse headache 1

2. Triptan timing: Triptans should be taken early in attack while pain is mild, but not during aura phase 1

3. Combination therapy superiority: Adding a triptan to an NSAID is more effective than either medication alone for moderate to severe migraine 1

4. Acetaminophen limitations: While effective for mild migraine, acetaminophen has inferior efficacy compared to NSAIDs and should be reserved for those who cannot tolerate NSAIDs 1, 2

5. Special populations: Treatment must be adjusted for older adults, children/adolescents, and pregnant women 1

By following this algorithm and adjusting treatment based on patient response, most headache patients can achieve significant improvement in their symptoms and quality of life.