What are the treatment options for headaches?

Treatment Options for Headaches

For acute headache treatment, start with NSAIDs or acetaminophen, and if inadequate relief occurs, add a triptan as combination therapy for optimal pain relief. 1, 2

First-Line Treatment Options

Mild to Moderate Headaches

• NSAIDs (recommended doses):
  • Ibuprofen 400-600mg
  • Naproxen sodium 500-550mg
  • Aspirin 800-1000mg 2
• Acetaminophen 1000mg (effective for mild-moderate headaches with 52-58% response rate vs 32-39% for placebo) 3, 4
• Combination of NSAID + acetaminophen (provides superior relief) 1

Moderate to Severe Headaches

• Combination therapy: Triptan + NSAID or triptan + acetaminophen 1
  • Begin treatment as soon as possible after headache onset
  • Sumatriptan 50mg orally (or 6mg subcutaneously for severe attacks with nausea/vomiting) 2, 5
  • Rizatriptan 10mg orally (for those ≥40kg) 2

Second-Line Treatment Options

For patients who don't respond to or cannot tolerate first-line treatments:

• CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant 1, 2
• Ergot alkaloid: dihydroergotamine 1
• Ditan: lasmiditan (consider only after failure of all other options) 1

Important Considerations

Medication Limitations to Prevent Overuse Headache

• NSAIDs: No more than 15 days per month 2
• Triptans: No more than 9-10 days per month 1, 2
• OTC medications: No more than 14 days per month 2

Contraindications and Cautions

• Avoid opioids and butalbital for acute migraine treatment 1, 2
• Triptans are contraindicated in patients with:
  • Coronary artery disease
  • Prinzmetal's variant angina
  • Uncontrolled hypertension
  • History of stroke or TIA 5
• Monitor for serotonin syndrome when combining triptans with SSRIs, SNRIs, TCAs, or MAO inhibitors 5

Special Situations

• For severe nausea/vomiting: Use non-oral triptan (nasal or injectable) with an antiemetic 1
• For pregnant/breastfeeding patients: Discuss risks and benefits of medications 1

Non-Pharmacological Approaches

Incorporate these alongside medication treatment:

• Lifestyle modifications:
  • Regular sleep schedule
  • Adequate hydration
  • Regular meals
  • Regular physical activity (moderate to intense aerobic exercise)
  • Stress management with relaxation techniques or mindfulness practices 1, 2
• Trigger identification and avoidance 2

Prevention for Frequent Headaches

Consider preventive therapy if:

• Headaches occur ≥2 times per month with disability lasting ≥3 days
• Acute treatments fail or are contraindicated
• Abortive medications are used more than twice weekly 2

First-line preventive options:

• Beta blockers
• Topiramate
• Candesartan
• Amitriptyline
• Divalproex sodium 2

Clinical Pearls

• Acetaminophen 1000mg is a reasonable option for those who cannot tolerate NSAIDs, with NNT of 12 for pain-free response at 2 hours 6
• High-dose aspirin (900-1300mg) is effective for acute migraine and may be considered for prevention (81-325mg daily) in patients with cost concerns 7
• Medication overuse headache occurs when acute medications are used too frequently (≥15 days/month for NSAIDs, ≥10 days/month for triptans) 1
• Patient education about early treatment initiation and medication limitations is crucial for effective management 1, 2