What are the recommended treatment guidelines according to TRIPP (Tension-type Headache, Migraine, and Cluster Headache Treatment and Research Initiative for Pain and Palliative care) for managing symptoms?

TRIPP Guidelines for Managing Tension-type Headache, Migraine, and Cluster Headache

For acute migraine treatment, the recommended first-line approach is combination therapy with a triptan and an NSAID or acetaminophen, which provides superior pain relief compared to monotherapy. 1

Migraine Management

Acute Treatment

• Begin with NSAIDs or acetaminophen for mild to moderate migraine attacks 1

  • Options include aspirin, ibuprofen, naproxen, or acetaminophen-aspirin-caffeine combination 1
  • Ensure adequate dosing before concluding treatment failure 1

• For moderate to severe attacks or inadequate response to NSAIDs/acetaminophen:

  • Add a triptan (sumatriptan, rizatriptan, eletriptan, frovatriptan, zolmitriptan) to an NSAID or acetaminophen 1
  • The combination of a triptan with an NSAID provides superior pain freedom and sustained pain relief compared to monotherapy 1

• For patients with inadequate response to triptan combinations:

  • Consider CGRP antagonists-gepants (rimegepant, ubrogepant, zavegepant) 1
  • Consider lasmiditan only if other treatments fail 1

• For patients with severe nausea/vomiting:

  • Use non-oral routes of administration (subcutaneous, intranasal) 1
  • Add antiemetics to treat nausea even if not vomiting 1

• Important cautions:

  • Do not use opioids or butalbital for acute migraine treatment 1
  • Begin treatment as soon as possible after migraine onset 1
  • Limit acute treatments to twice weekly to prevent medication overuse headache 1

Preventive Treatment

• Consider prevention for patients with:

  • Two or more attacks per month with disability lasting 3+ days 1
  • Inadequate response to acute treatments 1
  • Use of acute medications more than twice weekly 1
  • Presence of uncommon migraine conditions (hemiplegic, prolonged aura) 1

• First-line preventive options:

  • Beta-blockers (propranolol 80-240 mg/d, timolol 20-30 mg/d) 1
  • Amitriptyline (30-150 mg/d) 1
  • Divalproex sodium (500-1500 mg/d) or sodium valproate (800-1500 mg/d) 1
  • Atogepant for episodic migraine 1
  • OnabotulinumtoxinA for chronic migraine only 1

• Do not use:

  • Gabapentin for migraine prevention 1
  • OnabotulinumtoxinA for episodic migraine 1

Tension-Type Headache Management

Acute Treatment

• First-line treatment: Ibuprofen (400 mg) or acetaminophen (1000 mg) 1, 2
• Over-the-counter analgesics are typically effective for episodic tension-type headache 2
• Caution: Using pain relievers more than twice weekly increases risk of developing chronic daily headache 2

Preventive Treatment

• Amitriptyline is recommended for prevention of chronic tension-type headache 1, 2
• Avoid botulinum/neurotoxin injections for chronic tension-type headache prevention 1
• Consider non-pharmacological approaches like biofeedback, relaxation training, and cognitive therapy for frequent tension-type headaches 2

Cluster Headache Management

Acute Treatment

• First-line options:
  • Subcutaneous sumatriptan (6 mg) 1, 3
  • Intranasal zolmitriptan (10 mg) 1, 3
  • Normobaric oxygen therapy at flow rates of at least 12 L/min for 15 minutes 1, 3

Preventive Treatment

• For episodic cluster headache:

  • Galcanezumab is recommended as first-line prophylactic treatment 1, 3
  • Evidence is strongest for galcanezumab among available preventive options 3

• For chronic cluster headache:

  • Avoid galcanezumab 1
  • Insufficient evidence for verapamil in both episodic and chronic cluster headache 1

Medication Overuse Headache

• Define as headache occurring on 15+ days per month for at least 3 months due to overuse of acute medication 1
• Threshold for medication overuse varies by treatment type 1
• Insufficient evidence for specific preventive agents or withdrawal strategies 1
• Patient education about medication overuse is essential 1

Monitoring and Follow-up

• Track headache frequency, severity, duration, disability, treatment response, and adverse effects using daily flow sheets or diaries 1
• Identify and avoid headache triggers (alcohol, caffeine, certain foods, stress, fatigue, strong smells) 1, 3
• Counsel patients to begin treatment as early as possible in the headache attack 1
• Consider adding preventive medications if episodic headaches occur frequently or acute treatments don't provide adequate response 1