Should headache medications be given when a headache appears?

Headache Medication Management

Yes, headache medications should be given as soon as possible after a headache appears to maximize effectiveness and reduce symptom duration. 1, 2

Treatment Algorithm for Headache

First-Line Treatment

• For mild headaches:
  • Start with an NSAID (ibuprofen 400-600mg, naproxen sodium 500-550mg, or aspirin 800-1000mg) OR acetaminophen 1000mg 1, 2
  • The combination of an NSAID and acetaminophen may provide better relief than either medication alone 1

Second-Line Treatment

• If first-line treatment is inadequate:
  • Add a triptan to the NSAID or acetaminophen 1
  • For severe attacks or those with significant nausea/vomiting, consider non-oral triptan formulations (e.g., sumatriptan 6mg subcutaneously) 2, 3

Third-Line Treatment

• For patients who don't respond to or cannot tolerate triptans and NSAIDs:
  • Consider CGRP antagonists (gepants) such as rimegepant, ubrogepant, or zavegepant 1, 2
  • Consider the ditan lasmiditan for those who don't respond to all other treatments 1

Important Considerations

Timing of Administration

• Begin treatment as soon as possible after headache onset for maximum effectiveness 1
• Early intervention with appropriate medication leads to better pain relief and reduced disability 1, 3

Medication Overuse Risk

• Be aware of medication overuse headache risk:
  • NSAIDs: Limit to fewer than 15 days per month 1, 2
  • Triptans: Limit to fewer than 10 days per month 1, 2
  • Acetaminophen/OTC combinations: Limit to fewer than 14 days per month 2

Contraindications

• Avoid opioids and butalbital for headache treatment due to risk of medication overuse headache and poor outcomes 1, 2
• Triptans are contraindicated in patients with:
  • Coronary artery disease
  • Uncontrolled hypertension
  • History of stroke or TIA
  • Wolff-Parkinson-White syndrome 3

Special Populations

• For pregnant or breastfeeding patients, discuss the risks and benefits of medications 1
• For patients with severe nausea or vomiting, consider non-oral formulations and adding an antiemetic 1

Non-Pharmacological Approaches

While medication is important for acute treatment, also consider:

• Regular exercise, adequate hydration, and maintaining regular sleep schedule 2
• Identification and avoidance of triggers 2
• Relaxation techniques or mindfulness practices 1, 2

Clinical Pearls

• If a patient doesn't respond to one triptan, they may respond to another within the same class 1
• For patients with frequent headaches (≥2 per month with disability lasting ≥3 days), consider preventive therapy 2
• Counsel patients to track headache frequency, severity, duration, and response to treatment using a headache diary 2

Remember that early intervention with appropriate medication is key to effective headache management. The goal is to reduce pain, associated symptoms, and disability while minimizing the risk of medication overuse headache.