What are the treatment options for headaches in patients who cannot take Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)?

Treatment Options for Headaches in Patients Who Cannot Take NSAIDs

For patients who cannot take NSAIDs, acetaminophen (1000 mg) is the recommended first-line treatment for mild to moderate headaches, while triptans (such as sumatriptan) are recommended for moderate to severe migraines in patients without contraindications. 1, 2

Acute Treatment Options

First-Line Options

• Acetaminophen (1000 mg)

  • Statistically superior to placebo for acute migraine treatment 2
  • Safe option for patients with contraindications to NSAIDs 1
  • Particularly useful for mild to moderate headaches
  • No difference in adverse event rates compared to placebo 2

• Acetaminophen-caffeine combinations

  • Can provide enhanced efficacy compared to acetaminophen alone 1

Second-Line Options (for moderate to severe headaches)

• Triptans (e.g., sumatriptan)

  • Effective for moderate to severe migraines 3, 4
  • Important contraindications:
    • Coronary artery disease or Prinzmetal's angina
    • History of stroke or TIA
    • Uncontrolled hypertension
    • Wolff-Parkinson-White syndrome or other cardiac conduction disorders 3

• Metoclopramide (10 mg)

  • Can be used alone or in combination with acetaminophen
  • Acetaminophen 1000 mg plus metoclopramide 10 mg provides efficacy equivalent to oral sumatriptan 100 mg 2
  • Helps address nausea/vomiting associated with migraines
  • Warning: Risk of extrapyramidal symptoms and rarely neuroleptic malignant syndrome 5

Preventive Treatment Options for Recurrent Headaches

For patients with frequent headaches who cannot take NSAIDs, several preventive options are available:

• Beta-blockers

  • Propranolol (80-240 mg/day) or timolol (20-30 mg/day) 1
  • Caution: Use carefully in patients with asthma, diabetes, heart block, or bradycardia

• Angiotensin receptor blockers

  • Candesartan or telmisartan 1, 6
  • Good option for patients with comorbid hypertension

• Antidepressants

  • Amitriptyline (30-150 mg/day) 1

• Antiepileptic drugs

  • Topiramate (100 mg/day)
  • Divalproex sodium (500-1500 mg/day) 1

Non-Pharmacological Approaches

These approaches are particularly valuable for patients with contraindications to multiple medication classes:

• Behavioral interventions

  • Cognitive-behavioral therapy (CBT)
  • Biofeedback
  • Regular sleep schedule
  • Stress management 1

• Physical interventions

  • Regular aerobic exercise (as effective as some medications) 1

• Supplements

  • Oral magnesium (400-600 mg daily) - most evidence-supported supplement 1

Important Clinical Considerations

• Medication overuse: Using acute medications more than 10-15 days/month can perpetuate headaches 1, 3

• Special populations: Women with migraine with aura have higher stroke risk and require special consideration regarding hormonal therapies 1

• Monitoring: Maintain a headache diary to track frequency, intensity, duration, medication use, and potential triggers 1

• Referral criteria: Consider specialist referral after failure of two or more preventive medication trials, uncertain diagnosis, or complex comorbidities 1