Treatment Plans for Headache Disorders
For effective management of headache disorders including tension-type headache, cluster headache, and migraine, clinicians should implement specific evidence-based pharmacologic and non-pharmacologic interventions tailored to the headache type, with triptans, CGRP inhibitors, and NSAIDs forming the cornerstone of treatment. 1
Migraine Treatment
Acute Treatment
- Triptans are first-line treatment for moderate to severe migraine attacks, providing rapid relief 1
- Aspirin-acetaminophen-caffeine combinations are effective first-line options for acute migraine 1
- Newer CGRP inhibitors (gepants) are recommended as first-line options for acute migraine treatment 1
- Antiemetics should be considered for migraine attacks with significant nausea 1, 2
Preventive Treatment
- Angiotensin-receptor blockers and lisinopril are effective for episodic migraine prevention 1
- Topiramate and valproate are recommended preventive medications for episodic migraine 1
- CGRP monoclonal antibodies (eptinezumab) and atogepant are effective for migraine prevention 1
- AbobotulinumtoxinA is recommended for prevention of chronic migraine but not episodic migraine 1
- Gabapentin is not recommended for prevention of episodic migraine 1
Tension-Type Headache Treatment
Acute Treatment
- Ibuprofen (400 mg) is a first-line treatment for acute tension-type headache episodes 1
- Acetaminophen (1000 mg) is effective for acute tension-type headache treatment 1
- Avoid frequent and excessive use of analgesics to prevent medication-overuse headache 3, 4
Preventive Treatment
- Amitriptyline is the drug of first choice for prevention of chronic tension-type headache 1, 3
- Mirtazapine and venlafaxine are second-choice drugs for tension-type headache prevention 3, 4
- EMG biofeedback has documented efficacy for tension-type headache management 3, 4
Cluster Headache Treatment
Acute Treatment
- High-flow oxygen therapy (100% oxygen at 12 L/min via non-rebreather mask for 15 minutes) is first-line treatment for acute cluster headache attacks 5, 6
- Subcutaneous sumatriptan (6 mg) provides rapid relief for acute cluster headache attacks 5, 6, 7
- Intranasal zolmitriptan (10 mg) is an alternative to subcutaneous sumatriptan 5, 6
Preventive Treatment
- Galcanezumab is recommended as first-line prophylactic treatment for episodic cluster headache 5, 6
- Verapamil is commonly used for prevention, though evidence is less robust 5
Non-Pharmacologic Options
- Aerobic exercise is recommended for management of both tension-type headache and migraine 1
- Physical therapy can be beneficial for both tension-type headache and migraine management 1
- Noninvasive vagus nerve stimulation may be effective for episodic cluster headache 5
- Cognitive-behavioral therapy and relaxation training are likely effective for tension-type headache 3, 4
Important Considerations and Pitfalls
- Triptans carry cardiovascular risks including coronary artery vasospasm, transient ischemia, and myocardial infarction in patients with cardiovascular risk factors 7, 8, 7
- Serotonin syndrome may occur with triptans, particularly when combined with SSRIs or SNRIs 7, 8, 7
- Oxygen flow rates below 12 L/min may be insufficient for treating cluster headaches 5, 6
- Medication overuse can lead to chronic daily headache; limit analgesic use to prevent this complication 3, 4
- Opioids and butalbital-containing medications should be avoided for headache treatment 2
Treatment Algorithm
- Identify headache type based on clinical presentation
- For migraine:
- Acute: Use triptans, aspirin-acetaminophen-caffeine, or gepants based on severity
- Preventive: Consider angiotensin-receptor blockers, topiramate, CGRP inhibitors, or botulinum toxin (for chronic migraine)
- For tension-type headache:
- Acute: Use ibuprofen 400 mg or acetaminophen 1000 mg
- Preventive (if chronic): Amitriptyline as first choice
- For cluster headache:
- Acute: High-flow oxygen or subcutaneous sumatriptan
- Preventive: Galcanezumab for episodic cluster headache
- Incorporate appropriate non-pharmacologic approaches for all headache types