What is the guideline for emergency treatment of headache?

Emergency Treatment of Headache

For emergency treatment of headache, NSAIDs should be used as first-line therapy for acute migraine attacks, followed by triptans if NSAIDs fail, with combination therapy of a triptan and NSAID recommended for patients with inadequate response to monotherapy. 1

Initial Assessment and Classification

First, determine if the headache is primary or secondary:

• Red flag symptoms requiring immediate investigation:

  • Sudden onset/"thunderclap" headache
  • New headache in patients >50 years
  • Focal neurological deficits
  • Fever or signs of meningeal irritation
  • History of cancer or immunosuppression
  • Headache provoked by physical activities or postural changes 2

• Primary headaches (most common in ED):

  • Migraine (with or without aura)
  • Tension-type headache
  • Cluster headache
  • Other primary headache disorders 1, 2

Emergency Treatment Algorithm

1. First-Line Treatment for Acute Migraine

• NSAIDs:
  • Ibuprofen 400-600mg
  • Naproxen sodium 500-550mg 1

2. Second-Line Treatment (if NSAIDs fail)

• Triptans:

  • Sumatriptan: 6mg subcutaneously for severe attacks or significant nausea/vomiting, or 50mg orally (maximum 200mg in 24 hours)
  • Rizatriptan: 10mg orally
  • Eletriptan, frovatriptan, or zolmitriptan as alternatives 1

  Important triptan contraindications: Uncontrolled hypertension, cardiovascular disease, basilar or hemiplegic migraine 1

3. Combination Therapy

• Triptan + NSAID combination for inadequate response to monotherapy 1

4. Adjunctive Treatments

• Antiemetics (even if vomiting is not present):

  • Metoclopramide
  • Prochlorperazine 1

• Neuroleptic antiemetics are effective for acute migraine 3

5. Rescue Medications (for severe, refractory attacks)

• Corticosteroids for status migrainosus 4, 3
• Opioids (e.g., meperidine) or butalbital-containing compounds should be limited to rescue therapy only when other treatments fail 1

Special Considerations

Cluster Headache

• Requires specific treatment approach with high-flow oxygen and/or injectable/intranasal triptans 3

Status Migrainosus

• Parenteral treatment with NSAIDs, neuroleptic antiemetics, and corticosteroids 3

Pediatric Patients

• Ibuprofen is recommended for pain in children and adolescents
• For adolescents, consider sumatriptan/naproxen, zolmitriptan nasal, sumatriptan nasal, or rizatriptan ODT 1

Prevention of Medication Overuse Headache

• Limit triptan use to no more than 9 days per month
• OTC medications (e.g., ibuprofen, Excedrin Migraine): no more than 14 days per month
• NSAIDs: no more than 15 days per month 1

Post-Emergency Care

Referral to a Headache Center should be an integral part of the ED approach, as lack of follow-up involves a high rate of relapse and return visits to the ED 3.

Important Caveats

• IV hydration should be limited to cases of ascertained dehydration 3
• Avoid opioids as first-line treatment due to their scarce effectiveness in the acute phase and risk of medication overuse headache 1, 3
• Triptans should be limited to a maximum of 2 days per week to prevent medication overuse headache 1
• Patients with cardiovascular risk factors should avoid triptans; newer gepants (CGRP antagonists) may be safer alternatives in these patients 2, 5

The American Academy of Family Physicians and American College of Physicians guidelines emphasize that proper acute treatment can significantly reduce disability and improve quality of life for patients with headaches 4, 1.