What are the treatment options for headaches?

Treatment Options for Headaches in the Emergency Department

For acute migraine headaches, the most effective first-line treatment is combination therapy with a triptan plus a nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen, which should be initiated as early as possible after headache onset. 1

First-Line Treatment Options

For Mild to Moderate Migraine Attacks:

• NSAIDs (oral) such as ibuprofen 400-800 mg, naproxen sodium 275-550 mg, or aspirin 650-1000 mg 1
• Combination analgesics containing caffeine (e.g., aspirin plus acetaminophen plus caffeine) 1
• Acetaminophen 1000 mg (less effective than NSAIDs but useful for those who cannot tolerate NSAIDs) 2, 3

For Moderate to Severe Migraine:

• Triptan plus NSAID combination (strongest recommendation) 1
• Triptan plus acetaminophen when NSAIDs are contraindicated 1
• Sumatriptan is effective when taken early in an attack while pain is still mild 4

Second-Line Treatment Options

• CGRP antagonists (gepants) such as rimegepant, ubrogepant, or zavegepant for patients who don't respond to or cannot tolerate triptans plus NSAIDs 1
• Dihydroergotamine (DHE) as an alternative when first-line treatments fail 1
• Antiemetics like metoclopramide or prochlorperazine, particularly when migraine is accompanied by nausea/vomiting 1
• Non-oral routes of administration (intranasal, injectable) when severe nausea/vomiting is present 1

Third-Line Treatment Options

• Lasmiditan (ditan) for patients who don't respond to or cannot tolerate all other treatments 1
• Intranasal lidocaine (limited evidence for efficacy) 1
• Systemic steroids may be considered for status migrainosus (severe, continuous migraine lasting up to one week) 1

Important Cautions and Contraindications

• Do not use opioids or butalbital-containing medications for acute migraine treatment 1
• Opioids like meperidine and butorphanol should be avoided as they can lead to dependency, rebound headaches, and loss of efficacy 1
• Triptans are contraindicated in patients with coronary artery disease, Prinzmetal's angina, cerebrovascular disease, and uncontrolled hypertension 4
• Monitor for medication overuse headache, which can occur with frequent use of acute medications (≥15 days/month for NSAIDs, ≥10 days/month for triptans) 1

Special Considerations

• For patients with severe nausea/vomiting, use non-oral routes of administration and add an antiemetic 1
• If one triptan is ineffective, another within the same class may still provide relief 1
• Subcutaneous sumatriptan injection can be useful for patients who rapidly reach peak headache intensity or cannot take oral medications due to vomiting 1
• Discuss medication risks during pregnancy and lactation with patients of childbearing potential 1

Treatment Algorithm

1. Assess headache severity:

   • Mild to moderate: Start with NSAID or acetaminophen 1
   • Moderate to severe: Use triptan plus NSAID combination 1

2. If inadequate response to initial treatment:

   • Try a different triptan 1
   • Add an antiemetic if nausea/vomiting is present 1
   • Consider CGRP antagonists or dihydroergotamine 1

3. For refractory cases:

   • Consider lasmiditan 1
   • For status migrainosus, consider systemic steroids 1

4. Never use opioids or butalbital-containing medications for migraine treatment 1