What is the treatment for headaches?

Treatment for Headaches

For acute headache treatment, ibuprofen (400-800mg) or aspirin-acetaminophen-caffeine combinations are strongly recommended as first-line options, with naproxen sodium as an alternative NSAID if ibuprofen is ineffective. 1

Acute Treatment Algorithm

First-Line Options (Mild to Moderate Headaches)

• Simple analgesics:
  • Ibuprofen 400-800mg (strong recommendation) 1, 2
  • Acetaminophen 1000mg 1, 3
  • Aspirin-acetaminophen-caffeine combination (strongly recommended if available) 1
  • Naproxen sodium (alternative if ibuprofen ineffective) 1, 4

For Moderate to Severe Migraine Attacks

• Triptans (e.g., sumatriptan) are first-line for moderate to severe migraine attacks 2
  • Sumatriptan shows significant headache response at 2 and 4 hours post-treatment compared to placebo 5
  • Doses of 50mg and 100mg show better response than 25mg 5

Special Considerations

• For patients with cerebrovascular disease: acetaminophen (1000mg) or ibuprofen (400mg) are safest options 1
• Triptans should be avoided in patients with cerebrovascular disease 1
• Women with migraine with aura have significantly higher risk of ischemic stroke (RR 2.08) 1
• Combined hormonal contraceptives with estrogens are contraindicated in women with migraine with aura 1

Preventive Treatment for Recurrent Headaches

First-Line Preventive Medications

• Beta-blockers:
  • Propranolol (80-240 mg/day, starting at low doses) 1
  • Timolol (20-30 mg/day) 1

Alternative Preventive Options

• Angiotensin receptor blockers: Candesartan or telmisartan (strongly recommended) 1
• Tricyclic antidepressants: Amitriptyline (30-150 mg/day) 1
• Anticonvulsants:
  • Divalproex sodium (500-1500 mg/day) 1
  • Sodium valproate (800-1500 mg/day) 1
  • Topiramate (100 mg/day) 1

Advanced Preventive Options

• OnabotulinumtoxinA (Botox) 1
• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) 1

Non-Pharmacological Approaches

• Regular sleep schedule 1
• Stress management 1
• Regular aerobic exercise (as effective as relaxation therapy or topiramate in RCTs) 1
• Cognitive-behavioral therapy 1
• Biofeedback 1
• Oral magnesium (400-600mg daily) - most evidence-supported supplement 1

Important Caveats and Pitfalls

1. Medication overuse: Using acute medications more than 10-15 days/month may perpetuate headaches 1

   • Track with headache diary to monitor frequency, intensity, duration, medication use, triggers, and treatment response

2. Beta-blocker cautions: Use cautiously in patients with asthma, diabetes, heart block, or bradycardia 1

3. Avoid opioids and butalbital-containing medications unless other options have been ineffective 2

4. When to refer to specialist:

   • Failure of two or more preventive medication trials
   • Uncertain diagnosis
   • Complex comorbidities
   • Need for advanced treatments like onabotulinumtoxinA 1

5. Efficacy timing considerations: While ibuprofen and other NSAIDs are effective, acetaminophen 1000mg may provide faster relief at one hour compared to naproxen 375mg 4

The evidence strongly supports using NSAIDs as first-line treatment for most headaches, with triptans reserved for moderate to severe migraines. For prevention, beta-blockers and angiotensin receptor blockers have the strongest recommendations, with several other medication classes showing effectiveness.