What are the treatment options for headaches?

Treatment Options for Headaches

The most effective treatment approach for headaches depends on the specific headache type, with first-line treatments for migraines including NSAIDs (ibuprofen 400-800 mg, naproxen sodium 500-550 mg, aspirin 900-1000 mg) for mild to moderate attacks, and triptans for moderate to severe attacks. 1

Headache Classification and Initial Assessment

• Primary headaches: Migraine, tension-type headache, trigeminal autonomic cephalalgias
• Secondary headaches: Due to underlying medical conditions (vascular, neoplastic, infectious, intracranial pressure issues) 2

Red flags requiring immediate attention:

• Abrupt onset ("thunderclap") headache
• New headache in patients over 50 years
• Headache with neurological deficits
• Headache in immunocompromised patients
• Headache provoked by physical activity or postural changes 2, 3

Treatment Options by Headache Type

Migraine Treatment

Acute Treatment

1. Mild to moderate attacks:

   • NSAIDs: ibuprofen 400-800 mg, naproxen sodium 500-550 mg, aspirin 900-1000 mg
   • Acetaminophen 1000 mg (if NSAIDs contraindicated) 1

2. Moderate to severe attacks:

   • Triptans (e.g., sumatriptan) - most effective when taken early while headache is mild 1, 4
     • Sumatriptan shows significant headache response within 2-4 hours (50-62% at 2 hours vs 17-27% for placebo) 4
     • Contraindications: History of stroke, coronary artery disease, Wolff-Parkinson-White syndrome, uncontrolled hypertension 1, 4

3. For patients with prominent nausea/vomiting:

   • Anti-emetics: metoclopramide 10 mg, prochlorperazine 10 mg
   • Non-oral triptan formulations (nasal, injectable) with an antiemetic 1

4. Second-line options:

   • Gepants (CGRP antagonists) - safe for patients with cardiovascular contraindications to triptans 5, 2
   • Ditans (5-HT1F agonists) - also safe in patients with cardiovascular risk factors 2

Preventive Treatment

1. First-line preventives:

   • Beta-blockers: Propranolol 80-240 mg/day, Timolol 20-30 mg/day
   • Antidepressants: Amitriptyline 30-150 mg/day
   • Anticonvulsants: Topiramate 100 mg/day, Divalproex sodium 500-1500 mg/day
   • Angiotensin receptor blockers: Candesartan 8-32 mg/day 1

2. Second-line preventives:

   • CGRP monoclonal antibodies
   • OnabotulinumtoxinA (Botox) injections 1

Tension-Type Headache Treatment

• Simple analgesics: acetaminophen, NSAIDs
• Avoid overuse of medications (can lead to medication overuse headache) 5

Important Considerations and Precautions

Medication Overuse Headache

• Occurs with overuse of acute headache medications (≥10 days/month)
• Presents as increased frequency of headaches or daily headaches
• Treatment requires withdrawal of overused medications 4

Contraindications and Special Populations

• Triptans: Contraindicated in patients with:

  • History of stroke or TIA
  • Coronary artery disease
  • Uncontrolled hypertension
  • Wolff-Parkinson-White syndrome 1, 4

• NSAIDs: Use with caution in patients with:

  • Gastrointestinal disease
  • Renal disease
  • Cardiovascular disease 1

• Beta-blockers: Use with caution in patients with:

  • Asthma
  • Diabetes
  • Heart block
  • Bradycardia 1

• Women with migraine with aura:

  • Higher risk of ischemic stroke
  • Should avoid combined hormonal contraceptives with estrogens 1

Non-Pharmacological Approaches

• Regular sleep schedule
• Adequate hydration
• Regular meals
• Stress management techniques
• Regular physical exercise
• Cognitive-behavioral therapy and biofeedback
• Supplements: magnesium (400-600mg daily), riboflavin, coenzyme Q10 1

When to Refer to a Specialist

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

Regular follow-up is essential to monitor treatment effectiveness and adjust therapy as needed, using headache calendars to track frequency and medication use 1.