What are the treatment options for a unilateral headache?

Treatment Options for Unilateral Headache

For unilateral headache that is likely migraine, NSAIDs are the first-line treatment option, followed by triptans as second-line therapy if NSAIDs fail to provide adequate relief. 1

First-Line Treatment

• NSAIDs are recommended as first-line therapy for most patients with unilateral migraine headaches 2, 1

  • Aspirin (650-1000 mg every 4-6 hours)
  • Ibuprofen (400-800 mg every 6 hours)
  • Naproxen sodium (275-550 mg every 2-6 hours)
  • Diclofenac potassium

• Combination therapy of acetaminophen plus aspirin plus caffeine is effective (note that acetaminophen alone is not recommended for migraine) 2, 1

• Treatment should begin as early as possible during an attack for maximum efficacy 2

Second-Line Treatment

• Triptans should be offered to patients who do not respond adequately to NSAIDs 2

  • Options include sumatriptan, rizatriptan, naratriptan, and zolmitriptan
  • Most effective when taken early in an attack while headache is still mild 2
  • If one triptan is ineffective, others may still provide relief 2

• For patients with severe nausea or vomiting, consider:

  • Non-oral triptans (nasal spray, subcutaneous injection) 2
  • Adding an antiemetic such as metoclopramide or prochlorperazine 2, 1

Third-Line Treatment

• For patients who fail all available triptans or have contraindications to their use, consider: 2
  • CGRP antagonists-gepants (ubrogepant, rimegepant)
  • Ditans (lasmiditan)
  • Dihydroergotamine (intranasal or injectable)

Important Considerations

• Avoid opioids and butalbital for treating acute migraine headaches 2

  • These medications can lead to dependency and medication overuse headache

• Medication overuse headache is a risk when acute treatments are used too frequently: 2

  • ≥15 days per month with NSAIDs
  • ≥10 days per month with triptans

• Combination therapy (triptan with NSAID or acetaminophen) improves efficacy 2

• For frequent episodic migraine attacks, consider preventive medications: 2, 1

  • Propranolol (80-240 mg/d)
  • Timolol (20-30 mg/d)
  • Amitriptyline (30-150 mg/d)
  • Divalproex sodium/sodium valproate

Special Considerations for Unilateral Headaches

• While most unilateral headaches are migraine, consider other diagnoses such as: 3, 4, 5

  • Paroxysmal hemicrania (responds to indomethacin)
  • SUNCT/SUNA (Short-lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing/Cranial Autonomic symptoms)
  • Primary stabbing headache

• Patients with left-sided migraine may experience more frequent and severe headaches than those with right-sided migraine 3

• Imaging should be considered to rule out secondary causes of unilateral headache, particularly if the presentation is atypical for migraine 5

Lifestyle Modifications

• Counsel patients on important lifestyle modifications: 2
  • Maintaining adequate hydration
  • Regular meals
  • Sufficient and consistent sleep
  • Regular physical activity
  • Stress management techniques
  • Weight loss if overweight or obese