What are the treatment options for headache (cephalgia)?

From the Guidelines

For headache treatment, consider preventive treatment in patients who are adversely affected by migraine on ≥2 days per month despite optimized acute treatment, and use beta blockers, topiramate, or candesartan as first-line medications, as recommended by the most recent study 1.

Treatment Options

• For acute treatment, use ibuprofen to treat pain in children and adolescents, and consider sumatriptan/naproxen oral, zolmitriptan nasal, sumatriptan nasal, rizatriptan ODT, or almotriptan oral in adolescents, as suggested by 1.
• If one triptan is ineffective, try another or a non-steroidal anti-inflammatory drug-triptan combination, and if headache pain spikes quickly, try a non-oral triptan, as recommended by 1.
• For preventive treatment, consider CGRP monoclonal antibodies as third-line medications, and neuromodulatory devices, biobehavioural therapy, and acupuncture as adjuncts to acute and preventive medication or as stand-alone preventive treatment when medication is contraindicated, as suggested by 1.

Lifestyle Modifications

• Advise patients and families on lifestyle factors, migraine triggers, and avoidance of acute medication overuse, as recommended by 1.
• Counsel patients to treat acute migraine early in the attack, and to track potential triggers like stress, certain foods, or sleep patterns to prevent future episodes.

Important Considerations

• If nausea or vomiting is a significant component of the symptom complex, select a nonoral route of administration and treat nausea and vomiting with an antiemetic, as recommended by 1.
• Educate migraine sufferers about the control of acute attacks and preventive therapy, and engage them in the formulation of a management plan, as suggested by 1.

From the FDA Drug Label

The efficacy of sumatriptan tablets in the acute treatment of migraine headaches was demonstrated in 3, randomized, double-blind, placebo-controlled trials. A second dose of sumatriptan tablets or other medication was allowed 4 to 24 hours after the initial treatment for recurrent headache. Acetaminophen was offered to patients in Trials 2 and 3 beginning at 2 hours after initial treatment if the migraine pain had not improved or worsened Additional medications were allowed 4 to 24 hours after the initial treatment for recurrent headache or as rescue in all 3 trials.

The treatment options for headache (cephalgia) include:

• Sumatriptan tablets for the acute treatment of migraine headaches
• A second dose of sumatriptan tablets for recurrent headache
• Acetaminophen for migraine pain that has not improved or worsened
• Other medications as rescue or for recurrent headache 2

From the Research

Treatment Options for Headache (Cephalgia)

• The primary goals of acute migraine therapy are to reduce attack duration and severity, with current evidence-based therapies including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), triptans, NSAID-triptan combinations, dihydroergotamine, non-opioid combination analgesics, and several anti-emetics 3, 4.
• Triptans, such as sumatriptan and zolmitriptan, are effective in the acute treatment of cluster headaches and migraines, with different formulations (e.g., subcutaneous, intranasal, oral) offering varying pharmacokinetic, efficacy, and adverse event profiles 5, 6.
• Over-the-counter medications, including acetaminophen, ibuprofen, naproxen, and aspirin, are considered first-line therapy for mild-to-moderate migraine attacks due to their efficacy, lower cost, and favorable routes of administration 3, 7.
• Ibuprofen, in particular, has been shown to be an effective treatment for acute migraine headaches, providing pain relief in about half of sufferers, with a higher dose (400 mg) being more effective than a lower dose (200 mg) 7.
• Treatment principles, such as taking medication early in an attack and using a stratified treatment approach, can help ensure that migraine treatment is cost-effective 4.

Medication-Specific Treatment Options

• Sumatriptan formulations, including subcutaneous, intranasal, and oral options, offer different benefits and drawbacks, with the fastest and most complete migraine relief occurring with subcutaneous dosing 6.
• Zolmitriptan, administered orally or intranasally, has been shown to be effective in the acute treatment of cluster headaches, with an NNT of 2.8 for 30-minute pain relief 5.
• Acetaminophen and NSAIDs, such as ibuprofen, are first-line treatments for mild to moderate migraines, while triptans are first-line treatments for moderate to severe migraines 4.

Considerations for Treatment

• The choice of treatment should be individualized based on the pattern and severity of attacks, as well as the patient's preferences and medical history 4.
• The pharmacologic properties, potential adverse effects, cost, and routes of administration of different medications should be considered when selecting a treatment option 6, 4.