What are the recommended treatments for managing headaches and stomachaches?

Management of Headaches and Stomachaches

For headache management, NSAIDs are first-line treatment for most patients with migraine, while for stomachaches, treatment depends on the underlying cause.

Headache Management

First-Line Treatment for Acute Migraine

• NSAIDs are first-line treatment for most migraine patients 1, 2

  • Ibuprofen 400-800mg
  • Naproxen sodium 500-550mg
  • Aspirin 1000mg
  • Acetaminophen-aspirin-caffeine combination

• Acetaminophen (paracetamol) alone is generally ineffective for migraine 1, though it may be used for tension-type headaches 3

• For moderate to severe attacks when NSAIDs are ineffective, triptans are recommended:

  • Sumatriptan, rizatriptan, naratriptan, zolmitriptan 1, 2
  • Oral triptans reach effectiveness in 1-2 hours
  • Subcutaneous sumatriptan acts fastest (15 minutes) for severe attacks 2

Important Contraindications and Precautions

• Triptans are contraindicated in patients with 2, 4:

  • Coronary artery disease
  • Uncontrolled hypertension
  • History of stroke
  • Basilar or hemiplegic migraine
  • Wolff-Parkinson-White syndrome

• Limit acute medications to no more than 2 days per week to prevent medication overuse headache 2

• For patients with nausea/vomiting:

  • Use non-oral routes of administration 1
  • Add antiemetic medication 1
  • Metoclopramide 10mg plus paracetamol 1000mg has efficacy similar to oral sumatriptan 100mg 5

Preventive Treatment for Frequent Migraines

Preventive treatment should be considered when:

• Two or more migraine attacks per month with disability for 3+ days
• Rescue medication needed more than twice weekly
• Failure of acute treatments 1

First-line preventive medications 1, 2:

• Propranolol 80-240 mg/day
• Timolol 20-30 mg/day
• Amitriptyline 30-150 mg/day
• Divalproex sodium 500-1,500 mg/day
• Sodium valproate 800-1,500 mg/day
• Topiramate 100 mg/day

Stomachache Management

Treatment for stomachaches depends on the underlying cause:

For Acid-Related Disorders

• H2 receptor antagonists like ranitidine may be used for acid-related stomach pain 6
• Monitor for drug interactions with ranitidine, particularly with:
  • Warfarin (altered prothrombin time)
  • Procainamide (increased plasma levels)
  • Medications affected by gastric pH changes 6

For Migraine-Associated Stomach Pain

• Antiemetics should be added to migraine treatment when nausea/vomiting are present 1
• Non-oral routes of medication administration are preferred when significant nausea is present 1

Special Considerations

Medication Overuse

• Limit acute headache medications to no more than 2 days per week 2
• Overuse of acute migraine drugs (triptans, NSAIDs, opioids) for 10+ days/month can lead to medication overuse headache 4

Women's Health Considerations

• Women with migraine with aura should avoid combined hormonal contraceptives due to increased stroke risk 2
• Topiramate and valproate have teratogenic effects; effective birth control methods and folate supplementation are advised 2

When to Refer to a Specialist

• When two or more preventive medication trials fail
• When diagnosis is uncertain
• When complex comorbidities are present 2

Common Pitfalls to Avoid

1. Using acetaminophen alone for migraine (ineffective according to guidelines) 1
2. Prescribing triptans to patients with cardiovascular contraindications 4
3. Failing to address nausea/vomiting when present with migraine 1
4. Overusing acute medications, leading to medication overuse headache 4
5. Not considering preventive therapy for patients with frequent, disabling headaches 1, 2

Remember that over-the-counter medications are appropriate first-line therapy for mild-to-moderate migraine attacks, but patients with significant disability during most attacks should seek medical care for prescription options 7.