What are the treatment options for headaches?

Treatment Options for Headaches

For acute headache treatment, NSAIDs such as ibuprofen (400-800 mg) and naproxen sodium (500-550 mg) are first-line treatments for mild to moderate headaches, while triptans are first-line for moderate to severe attacks. 1

Acute Treatment Based on Headache Type and Severity

Mild to Moderate Headaches

• First-line options:
  • NSAIDs: Ibuprofen (400-800 mg) or naproxen sodium (500-550 mg)
  • Acetaminophen (1000 mg) - effective for migraine with 57.8% response rate at 2 hours 2
  • Limit use to 2-3 days/week to prevent medication overuse headache 1

Moderate to Severe Headaches/Migraines

• First-line options:

  • Oral triptans (sumatriptan, rizatriptan, eletriptan) 1
  • Sumatriptan shows 50-62% headache response at 2 hours compared to 17-27% for placebo 3
  • Triptan + acetaminophen combination provides better relief than either medication alone 1
  • Take triptans early in an attack while headache is still mild for best results 1

• Second-line options:

  • CGRP antagonists (gepants) such as rimegepant, ubrogepant, or zavegepant for patients who don't respond to or tolerate triptans 1
  • Antiemetics for migraine with significant nausea 4

Important Contraindications and Precautions

• Triptans are contraindicated in:

  • History of stroke or TIA
  • Coronary artery disease
  • Prinzmetal's variant angina
  • Wolff-Parkinson-White syndrome
  • Uncontrolled hypertension 3

• Avoid opioids and butalbital-containing medications due to risk of medication overuse headache and dependence 1, 4

Preventive Treatment

Preventive therapy should be considered for patients experiencing:

• 2-3 migraines weekly (8-12 monthly) 1
• Debilitating headaches 5
• Medication-overuse headaches 5

First-line Preventive Medications

• Beta-blockers: propranolol (80-240 mg/day) or timolol (20-30 mg/day) 1
• Topiramate (100 mg/day) - titrate slowly to minimize side effects 1
• Divalproex sodium (500-1500 mg/day) 1

Second-line Preventive Medications

• Tricyclic antidepressants: amitriptyline (30-150 mg/day) 1
• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) 1
• OnabotulinumtoxinA (Botox) for chronic migraine 1

Non-Pharmacologic Preventive Approaches

• Supplements with evidence:

  • Magnesium (400-600 mg daily) - most evidence-supported supplement 1
  • Riboflavin (vitamin B2) 1, 5
  • Coenzyme Q10 1, 5

• Lifestyle modifications:

  • Regular sleep schedule
  • Stress management techniques
  • Regular physical activity
  • Adequate hydration and regular meals 1

• Behavioral therapies:

  • Cognitive-behavioral therapy (CBT)
  • Biofeedback
  • Regular aerobic exercise (as effective as relaxation therapy or topiramate in trials) 1

Treatment Algorithm

1. Identify headache type and severity
2. For mild-moderate headaches: Start with NSAIDs or acetaminophen
3. For moderate-severe migraines: Use triptans or triptan+acetaminophen combination
4. If inadequate response: Consider second-line agents (gepants, antiemetics)
5. For frequent headaches (≥8 days/month): Add preventive therapy
6. Monitor for medication overuse: Limit acute treatments to 2-3 days/week
7. Consider specialist referral if: Two or more preventive medication trials fail, diagnosis uncertainty exists, or complex comorbidities are present 1

Special Considerations

• Women with migraine with aura are at higher risk of ischemic stroke and should avoid combined hormonal contraceptives with estrogens 1
• Maintain a headache diary to track frequency, severity, and medication effectiveness 1
• Assess effectiveness of preventive treatments after 6-8 weeks at therapeutic doses 1