What are the treatment options for headaches?

Treatment Options for Headaches

For migraine headaches, first-line treatments include NSAIDs (such as ibuprofen or naproxen), acetaminophen, or a combination of NSAID + acetaminophen for mild to moderate attacks, while triptans are recommended for moderate to severe attacks. 1

Acute Treatment of Migraine Headaches

First-Line Options

• Mild to Moderate Migraine Attacks:

  • NSAIDs (ibuprofen, naproxen)
  • Acetaminophen 1000 mg
  • Combination of NSAID + acetaminophen

• Moderate to Severe Migraine Attacks:

  • Triptans (e.g., sumatriptan 50-100 mg)
    • Clinical trials show 50-62% of patients achieve headache response within 2 hours with sumatriptan compared to 17-27% with placebo 2
    • Sumatriptan combined with naproxen provides enhanced efficacy 1
  • CGRP antagonists (gepants) such as rimegepant, ubrogepant, or zavegepant 1

Second-Line Options

• Triptan + NSAID combinations
• Antiemetics (when nausea is prominent)
• Acetaminophen 1000 mg + metoclopramide 10 mg (comparable efficacy to sumatriptan 100 mg) 3

Preventive Treatment for Recurrent Migraines

Consider preventive therapy if:

• Migraines occur ≥2 times per month
• Attacks are prolonged and disabling
• Quality of life is reduced between attacks 1

First-Line Preventive Medications

• 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)
  • Sodium valproate (800-1500 mg/day)
• Angiotensin receptor blockers:
  • Candesartan/telmisartan 1

Non-Pharmacological Approaches

Lifestyle Modifications

• Regular sleep schedule
• Consistent meal times
• Adequate hydration
• Regular physical activity
• Stress management techniques
• Identification and avoidance of personal triggers 1

Complementary Therapies

• Magnesium supplements (400-600 mg daily)
• Riboflavin supplements (400 mg daily)
• Coenzyme Q10 supplements
• Cognitive behavioral therapy
• Relaxation techniques 1

Special Considerations

Medication Overuse Headache Prevention

• Limit NSAIDs to ≤15 days/month
• Limit triptans to ≤10 days/month 1

Safety Precautions

• Triptans: Contraindicated in patients with:

  • Coronary artery disease
  • Prinzmetal's variant angina
  • Wolff-Parkinson-White syndrome
  • Uncontrolled hypertension 2
  • History of stroke or TIA

• Valproate derivatives: Avoid in female adolescents due to teratogenic potential 1

• Pregnancy: Acetaminophen is the safest acute option 1

Diagnostic Considerations

When evaluating headaches, rule out secondary causes by assessing "red flags":

• Headache worsened with Valsalva maneuver
• Headache that awakens patient from sleep
• New-onset headache in older patients
• Progressively worsening headache pattern
• Neurological symptoms or abnormal neurologic examination
• Headache during sexual activity 1

Treatment Algorithm

1. Assess headache severity: mild/moderate vs. moderate/severe
2. For mild to moderate attacks: Start with NSAIDs or acetaminophen
3. For moderate to severe attacks: Use triptans or CGRP antagonists
4. If nausea is prominent: Add an antiemetic
5. If attacks are frequent: Consider preventive therapy
6. Monitor for medication overuse: Limit acute medication use

Common Pitfalls

• Medication overuse can lead to chronic daily headaches
• Only 20% of patients who fulfill criteria for chronic migraine are correctly diagnosed 1
• Serotonin syndrome risk when triptans are combined with SSRIs, SNRIs, TCAs, or MAO inhibitors 2
• Overlooking the potential efficacy of over-the-counter options like acetaminophen, which has shown effectiveness with an NNT of 5.2 for 1-hour headache relief 4