What are the recommended treatments for headache management?

Recommended Treatments for Headache Management

For effective headache management, use acetaminophen, aspirin, ibuprofen, or naproxen as first-line treatments for migraine and tension-type headaches, with triptans or gepants reserved for moderate to severe migraines that don't respond to initial therapy. 1

Migraine Headache Management

Acute Treatment Algorithm

1. First-line options (mild to moderate attacks):

   • Ibuprofen 400 mg 1
   • Acetaminophen 1000 mg (not effective at lower doses) 1, 2
   • Aspirin 650-1000 mg 1, 3
   • Naproxen sodium 275-550 mg 4
   • Combination of acetaminophen + aspirin + caffeine 1

2. Second-line options (moderate to severe attacks or if first-line fails):

   • Triptans:
     • Sumatriptan 50-100 mg oral (shown to provide headache response in 50-62% of patients at 2 hours) 5
     • Rizatriptan 10 mg oral 4
     • Zolmitriptan oral 1
     • Sumatriptan 6 mg subcutaneous (for severe attacks with significant nausea/vomiting) 4
   • Newer CGRP inhibitors (gepants):
     • Rimegepant or ubrogepant 1

3. For patients with significant nausea/vomiting:

   • Use non-oral routes of administration 1
   • Add antiemetic treatment even if not vomiting 1
   • Consider greater occipital nerve block for short-term treatment 1

Preventive Treatment for Migraine

Consider preventive therapy when:

• Two or more attacks per month with disability lasting 3+ days per month
• Acute treatments fail or are contraindicated
• Medication use more than twice per week
• Presence of uncommon migraine conditions 1

Recommended preventive options:

• First-line:

  • Propranolol (80-240 mg/day) 1
  • Timolol (20-30 mg/day) 1
  • Divalproex sodium (500-1500 mg/day) 1
  • Sodium valproate (800-1500 mg/day) 1
  • Topiramate 1, 4
  • CGRP monoclonal antibodies 1, 4
  • Angiotensin receptor blockers (candesartan) 1, 4
  • Lisinopril 1
  • Magnesium 1
  • Memantine 1
  • Atogepant 1

• For chronic migraine only:

  • OnabotulinumtoxinA 1

• Not recommended:

  • Gabapentin (not effective for episodic migraine) 1
  • OnabotulinumtoxinA or abobotulinumtoxinA for episodic migraine 1

Tension-Type Headache Management

Acute Treatment

• Ibuprofen 400 mg 1
• Acetaminophen 1000 mg (note: lower doses not effective) 1

Preventive Treatment for Chronic Tension-Type Headache

• Amitriptyline (30-150 mg/day) 1
• Not recommended: Botulinum/neurotoxin injection 1

Cluster Headache Management

Acute Treatment

• Subcutaneous sumatriptan (6 mg) 1
• Intranasal zolmitriptan (10 mg) 1
• Normobaric oxygen therapy 1

Preventive Treatment

• For episodic cluster headache: Galcanezumab 1
• Not recommended for chronic cluster headache: Galcanezumab 1

Non-Pharmacologic Approaches

• Physical therapy for tension-type, migraine, or cervicogenic headache 1
• Aerobic exercise or progressive strength training for tension-type and migraine headache 1
• Noninvasive vagus nerve stimulation for episodic cluster headache 1

Important Cautions and Considerations

• Medication overuse risk: Limit acute therapy to avoid medication overuse headache:

  • NSAIDs: No more than 15 days per month 4
  • Triptans: No more than 9 days per month 4
  • OTC medications: No more than 14 days per month 4

• Cardiovascular risk: Use NSAIDs with caution in patients with cardiovascular risk factors 4

• Contraindications for triptans: Avoid in patients with cardiovascular conditions, uncontrolled hypertension, history of stroke/TIA 4

• Avoid: Intravenous ketamine for acute migraine treatment 1, patent foramen ovale closure 1, and IgG antibody testing for dietary trigger avoidance 1

By following this evidence-based approach to headache management, clinicians can effectively reduce headache frequency, intensity, and associated disability, thereby improving patients' quality of life and reducing the burden of this common neurological condition.