What are the treatment options for headaches?

Treatment Options for Headaches

For moderate to severe migraine headaches, a combination of a nonsteroidal anti-inflammatory drug (NSAID) plus a triptan is strongly recommended as the most effective treatment approach. 1

First-Line Treatment Options

For Mild to Moderate Headaches:

• Start with an NSAID:
  • Ibuprofen 400-800 mg
  • Naproxen sodium 500-550 mg (provides longer duration of action) 1
  • Acetaminophen 1000 mg (alternative for those who cannot tolerate NSAIDs) 1, 2

For Moderate to Severe Headaches:

• NSAID + triptan combination 1
• Acetaminophen + triptan for patients who don't respond to acetaminophen alone 1
• Aspirin + acetaminophen + caffeine (more effective than individual components) 1

Triptan Therapy

Sumatriptan and other triptans are effective for moderate to severe migraines:

• Clinical trials show 50-62% of patients achieve headache response within 2 hours with sumatriptan (compared to 17-27% with placebo) 3
• Sumatriptan doses:
  • 25 mg: Good efficacy with fewer side effects
  • 50 mg: Better response than 25 mg
  • 100 mg: Similar efficacy to 50 mg 3

Important safety considerations: Triptans are contraindicated in patients with coronary artery disease, Prinzmetal's variant angina, history of stroke/TIA, uncontrolled hypertension, and Wolff-Parkinson-White syndrome 3

For Headaches with Nausea/Vomiting

• Add metoclopramide 10 mg to treat nausea and improve gastric motility 1
• Prochlorperazine 10 mg IV with diphenhydramine 25 mg IV is recommended as second-line therapy 1
• Consider non-oral routes of administration for medications 1

Treatment Algorithm

1. Initial approach: Start with NSAID (ibuprofen 400-800 mg or naproxen 500-550 mg)
2. If inadequate response after 2 hours: Add a triptan
3. For significant nausea: Add an antiemetic (metoclopramide or prochlorperazine)
4. For severe, refractory headaches: Consider IV NSAIDs as first-line therapy 1

Preventive Medications

For patients with frequent headaches, consider preventive therapy:

• Propranolol (80-240 mg/day)
• Timolol (20-30 mg/day)
• Amitriptyline (30-150 mg/day)
• Divalproex sodium (500-1500 mg/day)
• Sodium valproate (800-1500 mg/day) 1

Important Precautions

• Avoid medication overuse: Limit use of acute medications to prevent medication overuse headaches 1, 3
• Limit opioids and butalbital-containing analgesics: These can lead to dependency and loss of efficacy 1
• Monitor for serotonin syndrome: Particularly when triptans are used with SSRIs, SNRIs, TCAs, or MAO inhibitors 3
• Cardiovascular risk: Triptans may cause vasospastic reactions and should be avoided in patients with cardiovascular disease 3, 4
• Pregnancy considerations: Valproate should be avoided in women of childbearing potential due to teratogenicity 1

When to Refer to a Specialist

Consider referral to a neurologist or headache specialist if:

• Headaches remain refractory to treatment
• Neurological symptoms accompany headaches
• Diagnostic uncertainty exists
• Headaches significantly impact quality of life despite management 1

Acetaminophen alone, while statistically superior to placebo, has a higher NNT (12) compared to other analgesics for achieving pain-free response at 2 hours, making it a less optimal choice than NSAIDs or combination therapies 2.