What are the treatment options for migraine and tension headaches?

Treatment Options for Migraine and Tension Headaches

For effective management of migraine and tension-type headaches, a stratified approach based on headache severity and frequency is recommended, with specific medications for acute treatment and prevention to reduce morbidity, mortality, and improve quality of life.

Acute Treatment of Migraine

First-line options:

• For mild to moderate migraines: NSAIDs and simple analgesics
  • Aspirin (325-1000 mg) 1
  • Ibuprofen (400-800 mg) 1
  • Naproxen sodium (500-550 mg) 1
  • Acetaminophen plus aspirin plus caffeine combination 1
  • Note: Acetaminophen alone is ineffective for migraine 1

Second-line options (for moderate to severe migraines):

• Triptans (5-HT1B/1D agonists)
  • Sumatriptan (25-100 mg oral, 5-20 mg intranasal, 6 mg subcutaneous) 2
  • Rizatriptan, naratriptan, zolmitriptan 1
  • Mechanism: Bind to 5-HT1B/1D receptors causing cranial vessel constriction and inhibition of pro-inflammatory neuropeptide release 2
  • Contraindications: Cardiovascular disease, uncontrolled hypertension, hemiplegic or basilar migraine 1

Third-line options:

• Dihydroergotamine (DHE) - intranasal formulation has good evidence 1
• CGRP receptor antagonists (gepants) for patients who cannot take triptans 1
• Antiemetics for associated symptoms 1

Preventive Treatment of Migraine

Indications for prevention:

• Two or more attacks per month with disability lasting 3+ days per month 1
• Failure of or contraindication to acute treatments 1
• Use of abortive medication more than twice per week 1
• Presence of uncommon migraine conditions (hemiplegic migraine, prolonged aura) 1

First-line preventive medications:

• β-Blockers

  • Propranolol (80-240 mg/day) - strong evidence 1
  • Timolol (20-30 mg/day) - strong evidence 1
  • Metoprolol, atenolol, nadolol - moderate evidence 1
  • Note: β-blockers with intrinsic sympathomimetic activity are ineffective 1

• Antidepressants

  • Amitriptyline (30-150 mg/day) - most evidence among antidepressants 1
  • Fluoxetine (20-40 mg/day) - limited evidence 1

• Anticonvulsants

  • Divalproex sodium/sodium valproate - good evidence 1
  • Topiramate - recommended in newer guidelines 1
  • Gabapentin is not recommended 1

• Newer options

  • CGRP monoclonal antibodies (erenumab, galcanezumab, fremanezumab, eptinezumab) 1
  • Atogepant (CGRP antagonist) 1

Acute Treatment of Tension-Type Headache

First-line options:

• NSAIDs
  • Ibuprofen (400 mg) 1
  • Acetaminophen (1000 mg) 1
  • Aspirin 3

Second-line options:

• Combination analgesics containing caffeine 3

Not recommended:

• Triptans, muscle relaxants, and opioids should not be used for tension headache 3

Preventive Treatment of Tension-Type Headache

First-line option:

• Amitriptyline - most evidence for chronic tension-type headache prevention 1, 3

Second-line options:

• Mirtazapine and venlafaxine 3

Non-Pharmacological Approaches

Physical interventions:

• Physical therapy - beneficial for both migraine and tension headache 1
• Aerobic exercise or progressive strength training (2-3 times/week for 30-60 minutes) 1

Behavioral interventions:

• Relaxation training 1
• Thermal biofeedback combined with relaxation training 1
• Cognitive-behavioral therapy 1

Treatment Strategy

For migraine:

1. Stratify treatment based on headache severity 1
   • Mild to moderate: Start with NSAIDs
   • Moderate to severe: Use migraine-specific medications (triptans)
2. Treat early in the attack for better efficacy 4
3. Consider preventive therapy if frequent attacks or significant disability

For tension-type headache:

1. Simple analgesics and NSAIDs for episodic tension headache 3
2. Amitriptyline for chronic tension headache 1, 3
3. Avoid frequent use of analgesics to prevent medication-overuse headache 3

Important Considerations and Pitfalls

• Medication overuse headache can develop with frequent use of acute medications (more than 2 days/week) 1
• Triptans should be avoided in patients with cardiovascular risk factors due to vasoconstrictive properties 5
• Propranolol is more effective for pure migraine, while amitriptyline is superior for mixed migraine and tension headache 1
• Valproate carries teratogenic risk (neural tube defects) and should be avoided in women of childbearing potential 1
• Combination of pharmacological and non-pharmacological approaches often yields better results 3