What is the treatment for severe headache?

Treatment for Severe Headache

For severe headache treatment, the first-line approach should be combination therapy with a triptan plus an NSAID or acetaminophen, which provides superior pain relief compared to monotherapy. 1

Stepwise Treatment Algorithm for Severe Headache

Initial Assessment

• Determine if headache is primary (migraine, tension, cluster) or secondary to underlying condition
• Rule out red flags requiring emergency evaluation:
  • Sudden onset ("thunderclap" headache)
  • New headache after age 50
  • Neurological deficits
  • Headache with fever or immunosuppression
  • Headache triggered by exertion or positional changes

First-Line Treatment for Severe Headache

1. For mild to moderate headache:

   • Start with NSAID (ibuprofen 400-800mg, naproxen sodium 275-550mg) or acetaminophen 1000mg 1

2. For moderate to severe headache:

   • Combination therapy: Triptan + NSAID or acetaminophen 1
     • Example: Sumatriptan 50-100mg + naproxen sodium 500mg
     • Initiate treatment as early as possible after headache onset

3. For severe headache with nausea/vomiting:

   • Consider non-oral triptan formulation (nasal spray, injection)
   • Add antiemetic (metoclopramide 10mg or prochlorperazine 25mg) 1

Second-Line Options (if inadequate response to first-line)

• CGRP antagonists (gepants): rimegepant, ubrogepant, zavegepant 1
• Dihydroergotamine (DHE) 1

Third-Line Option

• Ditan (lasmiditan) - for patients who don't respond to or tolerate other treatments 1

Rescue Medication

• Self-administered rescue medication for treatment failures
• Note: Do NOT use opioids or butalbital-containing compounds for migraine treatment 1

Medication Efficacy and Selection

Sumatriptan tablets show significant efficacy, with 50-62% of patients achieving headache response at 2 hours and 68-79% at 4 hours (compared to 17-27% and 19-38% with placebo) 2. The 50mg and 100mg doses show similar efficacy and both are superior to 25mg.

Important Considerations and Precautions

• Medication overuse headache risk: Limit acute treatments to no more than 2 days per week

  • NSAIDs: risk if used ≥15 days/month
  • Triptans: risk if used ≥10 days/month 1

• Triptan contraindications:

  • Coronary artery disease
  • Uncontrolled hypertension
  • History of stroke or TIA
  • Concurrent use of MAO inhibitors 2

• Serotonin syndrome risk:

  • Caution when combining triptans with SSRIs, SNRIs, or TCAs 2

• Preventive treatment indications:

  • Frequent headaches (≥2/month with ≥3 days disability)
  • Inadequate response to acute treatments
  • Acute medication use >2 days/week 1

Lifestyle Modifications

Always recommend these non-pharmacological approaches:

• Regular hydration
• Consistent meal timing
• Regular sleep schedule
• Physical activity (moderate to intense aerobic exercise)
• Stress management techniques
• Weight management if overweight/obese
• Identification and avoidance of personal triggers 1

By following this evidence-based algorithm, most patients with severe headache can achieve significant pain relief. Early intervention with combination therapy is key to optimizing outcomes and reducing headache-related disability.