What are the treatment modalities for headaches?

Treatment Modalities for Headache

The most effective approach to headache treatment should be stratified based on headache type, with triptans plus NSAIDs recommended as first-line therapy for moderate to severe migraine attacks, and ibuprofen (400 mg) or acetaminophen (1000 mg) for tension-type headaches. 1, 2

Diagnosis-Based Treatment Approach

Migraine Headache Treatment

Acute Treatment

1. Mild Migraine Attacks:

   • First-line: NSAIDs or acetaminophen
     • Ibuprofen 400-600 mg
     • Naproxen sodium 500-550 mg
     • Aspirin 800-1000 mg
     • Acetaminophen 1000 mg 2, 3, 4

2. Moderate to Severe Migraine Attacks:

   • First-line: Combination therapy of triptan plus NSAID 1, 2
     • The American College of Physicians strongly recommends adding a triptan to an NSAID for patients who don't respond adequately to NSAIDs alone 1
     • Sumatriptan 50 mg orally (for most patients) or 6 mg subcutaneously for severe attacks 2, 5

3. Second-line options:

   • CGRP Antagonists (Gepants) for patients who don't respond to or cannot tolerate triptans 2
   • Ditans (lasmiditan) for patients with cardiovascular contraindications to triptans 2, 6

Preventive Treatment

For patients with frequent migraines (≥2 attacks/month with disability lasting ≥3 days):

1. First-line preventive medications:

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

2. For episodic or chronic migraine:

   • CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) 2

Tension-Type Headache Treatment

1. Acute treatment:

   • Ibuprofen 400 mg (shows statistically significant improvement in pain-free response at 2 hours) 1
   • Acetaminophen 1000 mg (shows statistically significant improvement in pain-free response at 2 hours) 1, 4
   • Note: Acetaminophen doses lower than 1000 mg (e.g., 500-650 mg) did not show statistically significant improvement 1, 4

2. Preventive treatment for chronic tension-type headache:

   • Amitriptyline 50-100 mg (significantly reduces monthly headache days) 1
   • Note: OnabotulinumtoxinA is not recommended for chronic tension-type headache 1

Non-Pharmacologic Approaches

1. Physical Therapy:

   • Combination of thermal methods, trigger point massage, and mobilization/manipulation techniques 1
   • Shown to be better than sham interventions or medications at reducing headache frequency and intensity 1

2. Exercise:

   • Aerobic exercise or progressive strength training (2-3 times/week for 30-60 minutes) 1, 2
   • Particularly beneficial for both migraine and tension-type headache prevention 1

3. Other non-pharmacologic approaches:

   • Regular sleep schedule
   • Adequate hydration
   • Identification and avoidance of triggers
   • Relaxation techniques or mindfulness 2

Important Medication Limitations

1. To prevent medication overuse headache:

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

2. Avoid:

   • Opioids and butalbital-containing medications due to risk of medication overuse headache and worsening sleep 2, 7

Special Considerations

1. Cardiovascular risk:

   • Triptans should be avoided in patients with or at high risk for cardiovascular disease due to vasoconstrictive properties 5, 6
   • Consider gepants or ditans for patients with cardiovascular contraindications 6

2. Pregnancy:

   • Most migraine medications have limited safety data in pregnancy
   • Consult with specialists for pregnant patients with severe headaches

3. Elderly patients:

   • Use caution with amitriptyline due to anticholinergic adverse effects 1
   • Be aware of potential drug interactions in patients on multiple medications

When to Consider Referral

Consider referral to a headache specialist when:

• Headaches are refractory to standard treatments
• Unusual headache presentations or red flag symptoms are present
• Medication overuse headache is suspected
• Complex comorbidities exist that complicate management

Monitoring and Follow-up

• Track headache frequency, severity, duration, and response to treatment using a headache diary
• Monitor for adverse effects, especially with preventive medications
• Reassess treatment efficacy regularly and adjust as needed

The evidence strongly supports a stratified approach to headache treatment based on headache type and severity, with combination therapy showing superior efficacy for moderate to severe migraine attacks. Physical therapy and regular exercise provide additional benefits for both migraine and tension-type headache management.