What is the first line treatment for primary headaches?

First-Line Treatment for Primary Headaches

NSAIDs are the first-line treatment for most primary headaches, particularly aspirin, ibuprofen, naproxen sodium, and the acetaminophen-aspirin-caffeine combination. 1, 2

Treatment Algorithm for Primary Headaches

Step 1: Initial Assessment and First-Line Therapy

• For mild to moderate migraine headaches:

  • NSAIDs are first-line treatment 1, 2
    • Ibuprofen 400-600mg
    • Naproxen sodium 500-550mg
    • Aspirin 900-1300mg 3
    • Acetaminophen-aspirin-caffeine combination 1, 2
  • Note: Acetaminophen alone is ineffective for migraine 1

• Administration timing:

  • Take medication early in the headache phase for maximum effectiveness 1, 2
  • Limit use to no more than twice weekly to prevent medication overuse headache 1

Step 2: Second-Line Therapy (if NSAIDs are ineffective)

• For moderate to severe migraines or when NSAIDs fail:
  • Triptans (serotonin 5-HT1B/D agonists) 1, 2
    • Sumatriptan 50mg orally (most evidence) 4
    • Rizatriptan, naratriptan, zolmitriptan (all have good evidence) 1
  • Contraindications for triptans:
    • Uncontrolled hypertension
    • Basilar or hemiplegic migraine
    • Cardiovascular disease risk 1, 5

Step 3: Alternative Routes of Administration

• For patients with significant nausea/vomiting:
  • Use non-oral routes of administration 1
    • Sumatriptan subcutaneous injection (6mg) for severe attacks 2, 4
    • Intranasal DHE has good evidence for efficacy and safety 1
    • Add antiemetic medication to treat nausea 1

Step 4: Third-Line Options

• When triptans fail or are contraindicated:
  • Gepants (CGRP antagonists) like ubrogepant or rimegepant 1, 2
  • Ditans (5-HT1F agonists) like lasmiditan 1, 2
  • Consider opioids only when other medications cannot be used and after addressing abuse risk 1

Special Considerations

Medication Overuse Prevention

• Limit acute medications to prevent medication overuse headache 1, 2:
  • NSAIDs: No more than 15 days per month
  • Triptans: No more than 9 days per month
  • OTC combination medications: No more than 14 days per month

Preventive Therapy Indications

• Consider preventive treatment when 1, 2:
  • ≥2 migraine attacks per month with significant disability
  • Acute treatments are used more than twice weekly
  • Acute treatments fail or are contraindicated
  • Uncommon migraine conditions are present (e.g., hemiplegic migraine)

First-Line Preventive Medications

• Beta blockers (propranolol 80-240 mg/day, timolol 20-30 mg/day)
• Tricyclic antidepressants (amitriptyline 30-150 mg/day)
• Anticonvulsants (divalproex sodium 500-1,500 mg/day, sodium valproate 800-1,500 mg/day) 1, 2

Clinical Pearls and Pitfalls

• Key pitfall: Overuse of acute medications can lead to medication overuse headache, which can be difficult to treat 1, 2
• Important caveat: The comparative effectiveness of specific medications within the same class (e.g., different NSAIDs or different triptans) is not well established 1
• Practical tip: If one triptan is ineffective, others might still provide relief; patients should try at least 3 attacks with a medication before declaring it ineffective 1
• Safety note: Triptans should be avoided in patients with cardiovascular disease due to their vasoconstrictive properties 5

By following this evidence-based approach to primary headache management, clinicians can effectively treat most patients while minimizing adverse effects and preventing medication overuse headache.