What are the treatment options for headaches?

Treatment Options for Headaches

For headache treatment, start with NSAIDs or acetaminophen, and add a triptan for moderate to severe migraine headaches that don't respond to initial therapy. 1, 2

First-Line Treatment for Headaches

Mild to Moderate Headaches

• NSAIDs (such as ibuprofen 400-600mg, naproxen 500-550mg, diclofenac) 1, 2
• Acetaminophen (1000mg) 1, 2
• Combination of NSAID + acetaminophen for enhanced efficacy 1

NSAIDs provide pain relief in about half of migraine sufferers, with ibuprofen 400mg being more effective than 200mg when compared to placebo 3. Acetaminophen 1000mg has been shown to provide headache response in 57.8% of patients compared to 38.7% with placebo 4.

Moderate to Severe Migraine Headaches

When NSAIDs or acetaminophen alone don't provide adequate relief:

1. Add a triptan to NSAID (strong recommendation; moderate-certainty evidence) 1

   • Sumatriptan (50mg orally, 6mg subcutaneously for severe attacks) 2, 5
   • Rizatriptan (10mg orally) 2
   • Other options: almotriptan, eletriptan, frovatriptan, naratriptan, zolmitriptan 1

2. Add a triptan to acetaminophen if NSAIDs are contraindicated (conditional recommendation; low-certainty evidence) 1

Second-Line Treatment Options

For patients who don't respond to or cannot tolerate triptans and NSAIDs:

• CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant 1, 2

  • These medications eliminate headache symptoms for 2 hours in about 20% of patients 6
  • Higher cost than first-line options (annualized costs $4,959-$8,800) 1

• Ditan (lasmiditan) for patients who don't respond to all other treatments 1, 2

  • Safe option for patients with cardiovascular risk factors 6

Important Clinical Considerations

Medication Administration

• Begin treatment as soon as possible after headache onset 1, 2
• Use combination therapy (triptan + NSAID/acetaminophen) for improved efficacy 1
• For severe nausea/vomiting, consider non-oral triptan formulations with an antiemetic 1

Medications to Avoid

• Do not use opioids or butalbital for migraine treatment 1, 2
  • These can lead to medication overuse headache and worsen outcomes

Medication Overuse Prevention

• Limit NSAIDs to no more than 15 days per month 1, 2
• Limit triptans to no more than 10 days per month 1, 2
• Monitor for medication overuse headache (headache occurring ≥15 days/month for ≥3 months) 1

Non-Pharmacological Approaches

• Lifestyle modifications are important adjuncts to medication 1, 2:
  • Stay well hydrated
  • Maintain regular meals
  • Ensure sufficient and consistent sleep
  • Engage in regular physical activity (moderate to intense aerobic exercise)
  • Manage stress with relaxation techniques or mindfulness practices
  • Pursue weight loss if overweight/obese
  • Identify and avoid personal triggers

Preventive Treatment Considerations

Consider preventive medications if:

• Episodic migraine occurs frequently
• Treatment doesn't provide adequate response
• Headaches cause significant disability lasting 3+ days
• Patient uses acute medications more than twice weekly 1, 2

First-line preventive options include:

• Beta blockers
• Topiramate
• Candesartan
• Amitriptyline
• CGRP monoclonal antibodies 2

Special Populations

• Pregnancy and breastfeeding: Discuss potential adverse effects of medications during pregnancy and lactation 1
• Cardiovascular disease: Avoid triptans due to vasoconstrictive properties 5, 6

By following this evidence-based approach to headache treatment, most patients can achieve significant pain relief while minimizing adverse effects and preventing medication overuse headache.