What are the treatment options for severe headache management?

Severe Headache Management

For severe headache management, first-line treatment should include NSAIDs or acetaminophen for mild to moderate migraines, and triptans (such as sumatriptan) for moderate to severe migraines, with combination therapy providing the most effective relief. 1

Initial Treatment Algorithm

For Mild to Moderate Migraine Headaches:

• NSAIDs (aspirin, ibuprofen, naproxen) are first-line treatments for mild to moderate migraine attacks 1
• Combination analgesics containing caffeine with NSAIDs or acetaminophen can be more effective than monotherapy 1
• Isometheptene combinations may be effective for milder migraine headaches 1
• Acetaminophen alone is not recommended for migraine treatment but can be effective in combination with aspirin and caffeine 1

For Moderate to Severe Migraine Headaches:

• Triptans (sumatriptan, rizatriptan, zolmitriptan, naratriptan) are first-line treatments 1
• Oral triptans have shown 50-62% efficacy at 2 hours and 65-79% efficacy at 4 hours compared to placebo (17-27% at 2 hours, 19-38% at 4 hours) 2
• Dihydroergotamine (DHE) is an effective alternative for those who don't respond to triptans 1
• For patients with significant nausea/vomiting, use non-oral routes of administration (nasal, subcutaneous) 1

Combination and Rescue Therapy

• If NSAIDs or acetaminophen at adequate doses don't provide sufficient relief, add a triptan 1
• For severe migraine attacks not responding to first-line treatments, consider self-administered rescue medication such as opioids or butalbital-containing compounds 1
• Antiemetics (metoclopramide, prochlorperazine) should be used to treat accompanying nausea and improve gastric motility 1
• Limit opioid use due to risk of dependency, rebound headaches, and loss of efficacy 1

Status Migrainosus Management

• For status migrainosus (severe, continuous migraine lasting up to one week), intravenous corticosteroids are the mainstay of treatment 3
• Parenteral NSAIDs like ketorolac have a relatively rapid onset of action and six-hour duration 3
• Antiemetics are essential for accompanying nausea and impaired gastric motility 3
• Reserve opioids for cases not responding to other measures 3

Important Considerations and Cautions

• Limit acute therapy to no more than twice per week to prevent medication-overuse headache 1
• Medication-overuse headache can result from frequent use of acute medications, leading to increasing headache frequency and potentially daily headaches 1
• Patients who don't respond to one triptan may respond to another within the same class 1
• Triptans are contraindicated in patients with coronary artery disease, Prinzmetal's variant angina, uncontrolled hypertension, and history of stroke or TIA 2
• Monitor for serotonin syndrome when triptans are used with SSRIs, SNRIs, TCAs, or MAO inhibitors 2
• Gepants (rimegepant, ubrogepant) or ergot alkaloids can be considered for patients who don't tolerate or have inadequate response to combination therapy 1

Preventive Treatment Considerations

• Consider preventive therapy when: (1) two or more attacks per month produce disability lasting 3+ days per month, (2) acute treatments fail or are contraindicated, (3) abortive medications are used more than twice weekly, or (4) uncommon migraine conditions are present 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
• Lifestyle modifications including hydration, regular meals, sufficient sleep, regular physical activity, and stress management should be emphasized 1

Special Situations

• For patients with cardiovascular disease, avoid triptans and consider NSAIDs or antiemetics 3
• For pregnant patients, acetaminophen and antiemetics are preferred; avoid NSAIDs and triptans 3
• In cases of medication overuse contributing to headaches, discontinuation of the overused medication is essential 3