What is the next step in treating a patient with a headache that is not responding to Tylenol (acetaminophen) and acetaminophen?

Treatment for Headache Not Responding to Acetaminophen

For a patient with headache not responding to acetaminophen, the next step should be to add a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen or naproxen, or if the headache is moderate to severe, consider adding a triptan medication. 1

Assessment of Headache Type and Severity

Before proceeding with treatment, quickly determine:

• If this is a migraine or tension-type headache
• Severity (mild, moderate, or severe)
• Associated symptoms (nausea, vomiting, photophobia, phonophobia)
• Previous response patterns to medications

Treatment Algorithm

Step 1: Optimize Current Therapy

• Ensure adequate acetaminophen dosing (up to 1000 mg) has been tried 1
• Acetaminophen alone has limited efficacy for migraine but may help tension headaches 1, 2

Step 2: Add or Switch to NSAID

• For mild to moderate headache: Add an NSAID 1
  • Ibuprofen 400-800 mg every 6 hours (max 2.4g/day)
  • Naproxen sodium 275-550 mg every 2-6 hours (max 1.5g/day)
  • Aspirin 650-1000 mg every 4-6 hours (max 4g/day)

Step 3: For Moderate to Severe Headache or Poor NSAID Response

• Add a triptan (particularly if migraine features are present) 1
  • Sumatriptan 50-100 mg orally (evidence shows 50mg is often sufficient) 3, 4
  • Other options: rizatriptan, zolmitriptan, naratriptan, almotriptan, eletriptan
  • Triptans should be taken early in the attack for best efficacy

Step 4: Combination Therapy

• Consider combination therapy of NSAID plus triptan 1
• Alternatively, try combination of aspirin + acetaminophen + caffeine 1, 5
  • This combination has shown superior efficacy to monotherapy 5

Step 5: For Headache with Significant Nausea/Vomiting

• Use non-oral route of administration 1
• Add an antiemetic such as metoclopramide or prochlorperazine 1
• Consider non-oral triptan formulations (nasal spray, injection) 1, 4

Important Considerations and Cautions

• Avoid opioids and butalbital-containing medications for headache treatment 1

  • These can lead to dependency, rebound headaches, and loss of efficacy

• Watch for medication overuse headache 1

  • Occurs with frequent use (≥15 days/month with NSAIDs, ≥10 days/month with triptans)
  • May require preventive therapy if headaches are frequent

• Contraindications to triptans 1

  • Uncontrolled hypertension
  • Coronary artery disease or risk factors
  • Basilar or hemiplegic migraine
  • MAO inhibitor use within 15 days

• For severe, refractory headaches:

  • Consider parenteral options like ketorolac (60 mg IM) for severe attacks 1
  • Dihydroergotamine or CGRP antagonists (gepants) may be considered for patients who don't respond to triptans and NSAIDs 1

Follow-up Recommendations

• If headaches remain frequent or severe despite acute treatment, consider preventive medications 1
• Encourage lifestyle modifications: hydration, regular meals, consistent sleep, stress management 1
• Track headache patterns and medication response to guide future treatment

Remember that early intervention with appropriate medication at adequate doses is key to effective headache management. The combination of medications often works better than monotherapy for difficult-to-treat headaches.