Management Plan for Headaches
The management of headaches should follow a stratified approach based on headache type, severity, and frequency, with appropriate pharmacologic and non-pharmacologic interventions tailored to each specific headache disorder. 1
Diagnosis and Classification
- Headaches are broadly categorized into primary headache disorders (migraine, tension-type headache, trigeminal autonomic cephalalgias) and secondary headache disorders (due to underlying medical conditions) 2
- Tension-type headache is the most common primary headache disorder with a 26% global prevalence, while migraine affects approximately 12% of the population 1
- Evaluation should determine whether the headache is primary or secondary, with attention to red flags suggesting urgent medical problems (abrupt onset, neurologic signs, age ≥50 years, cancer/immunosuppression, provocation by physical activities) 2
Management of Migraine Headaches
Acute Treatment for Migraine
- For mild to moderate migraine attacks, use NSAIDs (oral) as first-line therapy 1
- For moderate to severe migraine or migraines that respond poorly to NSAIDs, use migraine-specific drugs such as triptans or combination therapy 1
- Triptans (sumatriptan, naratriptan, rizatriptan, zolmitriptan) are effective for moderate to severe attacks, eliminating pain in 20-30% of patients within 2 hours 3, 2
- Newer calcitonin gene-related peptide (CGRP) inhibitors (gepants) are additional options for acute migraine treatment 1
- For migraine with nausea or vomiting, use a non-oral route of administration and consider antiemetics 1
- Limit and carefully monitor the use of opiates and butalbital-containing analgesics to avoid dependency and medication overuse headache 1
Preventive Treatment for Migraine
- Consider preventive therapy for patients with: two or more attacks per month producing disability lasting 3+ days per month, contraindication to/failure of acute treatments, use of abortive medication more than twice per week, or uncommon migraine conditions 1
- First-line preventive agents include propranolol (80-240 mg/d), timolol (20-30 mg/d), amitriptyline (30-150 mg/d), divalproex sodium (500-1500 mg/d), and sodium valproate (800-1500 mg/d) 1
- Newer options include angiotensin-receptor blockers, lisinopril, magnesium, topiramate, CGRP monoclonal antibodies, and atogepant 1
- AbobotulinumtoxinA can be used for prevention of chronic migraine but is not recommended for episodic migraine 1
- Gabapentin is not recommended for prevention of episodic migraine 1
Management of Tension-Type Headache (TTH)
Acute Treatment for TTH
- For acute TTH, ibuprofen (400 mg) or acetaminophen (1000 mg) are recommended as they demonstrate significant improvement in pain-free response at 2 hours 1
- Note that acetaminophen doses lower than 1000 mg (e.g., 500-650 mg) do not show statistically significant improvement 1, 4
- Combination analgesics containing caffeine may also be effective 1
Preventive Treatment for TTH
- Amitriptyline at 50 mg and 100 mg is recommended for preventive treatment of chronic TTH as it significantly reduces monthly headache days 1
- OnabotulinumtoxinA is not recommended for chronic TTH as it does not show significant improvement in critical outcomes 1
Non-Pharmacologic Therapies
- Physical therapy is beneficial in managing both migraine and TTH, using a combination of thermal methods, trigger point massage, and mobilization/manipulation techniques 1
- Aerobic exercise or progressive strength training (2-3 times per week for 30-60 minutes) is recommended for prevention of both migraine and TTH 1
- Evidence is insufficient to recommend for or against biofeedback, smartphone application-based heart rate variability monitoring, cognitive behavioral therapy, mindfulness-based therapies, and progressive muscle relaxation 1
Important Considerations and Pitfalls
- Medication overuse headache can develop with frequent use of acute headache medications (≥10 days/month), presenting as daily headaches or increased frequency of attacks 3
- Triptans should be avoided in patients with or at high risk for cardiovascular disease due to their vasoconstrictive properties 2
- Sumatriptan may cause coronary artery vasospasm (Prinzmetal's angina) and is contraindicated in patients with coronary artery disease 3
- Serotonin syndrome may occur with sumatriptan, particularly during co-administration with SSRIs, SNRIs, TCAs, and MAO inhibitors 3
- Anticholinergic adverse effects of amitriptyline should be monitored, especially in older patients and those with cardiac comorbidities 1