What are the recommended treatments for acute headaches?

Acute Treatment for Headaches

For acute headache treatment, NSAIDs or acetaminophen are recommended as first-line therapy for mild to moderate migraines, while triptans should be added for moderate to severe migraines or when first-line treatments fail. 1

First-Line Treatment Options

Mild to Moderate Headaches

• NSAIDs:

  • Ibuprofen 400-800mg
  • Naproxen 500-550mg
  • These medications have demonstrated efficacy with NNTs of 3.2 for headache relief at 2 hours for ibuprofen 400mg 2

• Acetaminophen:

  • 1000mg dose
  • Provides headache relief in approximately 58% of patients at 2 hours compared to 39% with placebo 3
  • Good option for patients who cannot tolerate NSAIDs 1
  • Has a favorable safety profile but lower efficacy compared to NSAIDs 4

Second-Line Treatment Options

Moderate to Severe Headaches

• Triptans:
  • Should be added to NSAIDs or acetaminophen when first-line treatments fail 1
  • Options include sumatriptan, rizatriptan, zolmitriptan, almotriptan, eletriptan, frovatriptan, or naratriptan
  • Sumatriptan 50mg and 100mg provide significant headache response at 2 hours (50-62% response rate) 5
  • Caution in patients with cardiovascular risk factors 1

For Patients with Severe Nausea/Vomiting

• Non-oral triptans with antiemetics should be considered 1
• Soluble formulations of medications (like ibuprofen) provide more rapid relief than standard tablets 2

Treatment Algorithm

1. Assess headache severity:

   • Mild to moderate → Start with NSAIDs or acetaminophen
   • Moderate to severe → Consider starting with triptan or NSAID + triptan combination

2. For mild to moderate headaches:

   • Start with ibuprofen 400-800mg OR naproxen 500-550mg OR acetaminophen 1000mg
   • If pain has significant occipital component, consider greater occipital nerve block 1

3. If inadequate response to first-line treatment:

   • Add a triptan (e.g., sumatriptan 50-100mg)
   • Consider switching to another medication in the same class before moving to next line 1

4. For patients with severe nausea/vomiting:

   • Use non-oral route of administration
   • Consider antiemetics in combination with pain medication
   • Paracetamol (acetaminophen) plus metoclopramide 10mg shows efficacy equivalent to oral sumatriptan 100mg 4

Important Considerations

• Timing: Start treatment as early as possible after onset for improved efficacy 1
• Medication overuse: Limit acute medications to ≤10 days per month to prevent medication overuse headache 1
• Avoid: Opioids and butalbital should be avoided due to risk of medication overuse headache 1
• Route of administration: Oral is standard, but non-oral routes may be necessary for those with severe nausea/vomiting 1

Special Situations

• Dihydroergotamine (DHE): Effective option but contraindicated in pregnancy 1
• Butorphanol nasal spray: Has evidence for efficacy but should be used cautiously due to potential for dependence 1
• Cardiovascular risk: Triptans should be used with caution in patients with cardiovascular risk factors 1
• Serotonin syndrome: Risk should be considered when combining triptans with other serotonergic medications 1

When to Consider Referral

Consider referral to a neurologist if headaches remain refractory to multiple treatment options 1