What are the recommended management options for headache treatment?

Headache Medicine Management

For effective headache management, use triptans (eletriptan, frovatriptan, rizatriptan, sumatriptan, or zolmitriptan) as first-line treatment for moderate to severe migraine attacks, and NSAIDs (ibuprofen, naproxen) or acetaminophen for mild to moderate headaches. 1, 2

Migraine Treatment Algorithm

Acute Treatment for Migraine

First-Line Options:

• For mild to moderate attacks:

  • Ibuprofen 400 mg or acetaminophen 1000 mg 1, 3
  • Aspirin-acetaminophen-caffeine combination 1, 2
  • Naproxen 1

• For moderate to severe attacks:

  • Oral triptans: sumatriptan 50 mg, rizatriptan 10 mg, zolmitriptan 1, 2, 4
  • For severe attacks with significant nausea/vomiting: subcutaneous sumatriptan 6 mg 2, 4

The VA/DoD guidelines strongly recommend eletriptan, frovatriptan, rizatriptan, sumatriptan, and zolmitriptan for short-term migraine treatment 1. Clinical trials show that sumatriptan provides headache relief in 50-62% of patients within 2 hours compared to 17-27% with placebo 4.

Second-Line Options:

• Rimegepant or ubrogepant (CGRP antagonists) 1, 5
• Greater occipital nerve block for short-term treatment 1

Tension-Type Headache Treatment

• First-line treatment: Ibuprofen 400 mg or acetaminophen 1000 mg 1
• For chronic tension-type headache prevention: Amitriptyline 1
• Not recommended: Botulinum toxin injections 1

Cluster Headache Treatment

• Acute treatment:
  • Subcutaneous sumatriptan 6 mg or intranasal zolmitriptan 10 mg 1
  • Normobaric oxygen therapy 1
• Prevention:
  • Galcanezumab for episodic cluster headache 1
  • Not recommended: Galcanezumab for chronic cluster headache 1

Preventive Treatment Considerations

Consider preventive therapy when:

• Patient experiences two or more attacks per month with disability lasting 3+ days
• Acute treatments fail or are contraindicated
• Medication overuse occurs 2

Recommended preventive options:

• Beta-blockers (propranolol 80-240 mg/d, timolol 20-30 mg/d)
• Anticonvulsants (topiramate)
• Antidepressants (amitriptyline 30-150 mg/d)
• CGRP monoclonal antibodies 2

Not recommended: Gabapentin for episodic migraine prevention 1

Important Precautions and Contraindications

Medication Overuse Headache Prevention

• Limit triptan use to no more than 9 days per month 2, 4
• Limit OTC medications to no more than 14 days per month 2
• Limit NSAIDs to no more than 15 days per month 2

Triptan Contraindications

• Ischemic heart disease
• Previous myocardial infarction
• Prinzmetal's angina
• Uncontrolled hypertension
• Wolff-Parkinson-White syndrome or other cardiac conduction disorders 2, 4

Serious Adverse Effects to Monitor

• Serotonin syndrome (when combining triptans with SSRIs, SNRIs, TCAs, or MAO inhibitors) 4
• Cerebrovascular events (stroke, hemorrhage, TIA) 4
• Vasospastic reactions 4

Lifestyle Modifications and Non-Pharmacologic Approaches

• Regular sleep schedule
• Regular meals
• Moderate aerobic exercise
• Stress management techniques
• Headache diary to identify triggers 2
• Physical therapy for tension-type, migraine, or cervicogenic headache 2

Follow-up and Evaluation

Schedule follow-up in 4-6 weeks to assess treatment effectiveness and adjust as needed. Evaluate for high-risk factors including anxiety, depression, and medication overuse 2.

Remember that the overuse of acute migraine medications can lead to medication overuse headache, which presents as increased frequency of migraine attacks or daily headaches 4. Detoxification may be necessary in these cases.