What is the recommended treatment for intractable headaches in an urgent care setting?

Urgent Care Treatment for Intractable Headache

For intractable headaches in urgent care settings, the first-line treatment should be a combination of a triptan (such as sumatriptan) with an NSAID (such as naproxen), along with an antiemetic if nausea is present. 1

Initial Assessment and Treatment Algorithm

Step 1: Rule Out Secondary Causes

• Check for "red flags" suggesting secondary headache:
  • Sudden onset, "worst headache of life"
  • Fever, neck stiffness
  • Focal neurological deficits
  • Recent head trauma
  • Immunocompromised status
  • New onset after age 50

Step 2: Treatment of Primary Headache (Migraine)

For Moderate to Severe Attacks:

1. First-line combination therapy:

   • Sumatriptan 50mg + Naproxen 500mg 1, 2
   • Add antiemetic (e.g., metoclopramide 10mg IV) if nausea is present 1, 2

2. If inadequate response after 2 hours:

   • Consider non-oral route of administration:
     • Sumatriptan subcutaneous injection 6mg OR
     • Sumatriptan intranasal spray OR
     • Dihydroergotamine (DHE) nasal spray 1, 2

3. For patients with contraindications to triptans:

   • Use NSAID monotherapy (naproxen 500mg) 1, 2
   • Consider acetaminophen-aspirin-caffeine combination (Excedrin) 2
   • Add antiemetic for nausea 1

Important Considerations

Medication Contraindications

• Do NOT use triptans in patients with:
  • Uncontrolled hypertension
  • Coronary artery disease
  • Basilar or hemiplegic migraine
  • Recent use of ergotamine (within 24 hours)
  • Recent use of MAO inhibitors 3, 4

Critical Warnings

• Do NOT use opioids or butalbital for acute migraine treatment 1
• Limit triptan use to no more than 9 days per month to prevent medication overuse headache 1, 2
• Limit NSAID use to no more than 15 days per month 1, 2

For Truly Intractable Cases

• Consider parenteral treatment with ketorolac IV/IM 5
• For status migrainosus (prolonged attack >72 hours), consider:
  • IV hydration if dehydrated
  • Dexamethasone 10mg IV/IM as a single dose 1, 5
  • Naratriptan 2.5mg twice daily (off-label) has shown efficacy in intractable migraine 6

Follow-up Recommendations

• Refer to a headache specialist if:

  • Headaches occur more than twice weekly
  • Patient uses acute medications more than twice weekly
  • Current attack required urgent care visit 1, 2

• Educate patient about:

  • Starting treatment as early as possible in the headache course
  • Lifestyle modifications (hydration, regular meals, sleep hygiene)
  • Identifying and avoiding personal triggers 1
  • Risk of medication overuse headache with frequent use of acute treatments

Special Populations

• Pregnant/breastfeeding patients:
  • Discuss risks/benefits of medications
  • NSAIDs may be safer in early pregnancy but should be avoided in third trimester
  • Acetaminophen is generally considered safest 1

The American College of Physicians' 2025 guidelines strongly emphasize combination therapy with triptans and NSAIDs for optimal efficacy in acute migraine treatment, with specific cautions against opioid use 1. This approach has been shown to provide superior pain relief compared to monotherapy options, making it the most effective strategy for treating intractable headaches in the urgent care setting.