Management of Mixed-Type Headaches
For patients with mixed-type headaches, treatment should target each headache type separately, using a combination of therapies for both migraine and tension-type headache components, while avoiding medication overuse. 1, 2
Diagnostic Approach
- Properly identify the specific headache types present in the mixed presentation (commonly migraine and tension-type headache) 2
- Distinguish between episodic migraine (<15 headache days/month) and chronic migraine (≥15 headache days/month with migraine features on ≥8 days) to guide appropriate treatment selection 1
- Monitor for medication overuse headache, especially in patients with risk factors including headache frequency ≥7 days/month, frequent use of anxiolytics, analgesics, or sedative hypnotics, and history of anxiety or depression 1
Acute Treatment Strategies
For Migraine Component:
- First-line options include aspirin-acetaminophen-caffeine combinations, which show significant improvement in critical outcomes (NNT of 9 for pain freedom at 2 hours) 1
- Triptans remain cornerstone therapy for moderate to severe migraine attacks 1, 3
- CGRP antagonists (gepants) such as ubrogepant and rimegepant are effective alternatives, particularly for patients with cardiovascular contraindications to triptans 1, 3
- For migraine with significant nausea or vomiting, use non-oral routes of administration and consider antiemetics 2
For Tension-Type Headache Component:
- Ibuprofen (400 mg) and acetaminophen (1000 mg) are recommended for acute treatment of tension-type headache 4
- Combination analgesics containing caffeine may also be effective for acute tension-type headache 2
Important Considerations:
- Avoid opioids and butalbital-containing medications for routine treatment due to risk of medication overuse headache 1, 3
- When both headache types occur simultaneously, target the predominant type first 2
Preventive Treatment Strategies
For Migraine Component:
- CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) have strong recommendations for prevention of both episodic and chronic migraine 1
- Angiotensin receptor blockers (candesartan, telmisartan) have strong recommendations for episodic migraine prevention 1
- Topiramate has a weak recommendation for prevention of both episodic and chronic migraine 1
- OnabotulinumtoxinA is recommended specifically for prevention of chronic migraine (but not episodic migraine) 4, 1
For Tension-Type Headache Component:
- Amitriptyline is recommended for prevention of chronic tension-type headache 4, 2
- Amitriptyline may be particularly beneficial for mixed migraine and tension-type headache 4
Non-Pharmacologic Approaches:
- Aerobic exercise or progressive strength training (typically 2-3 times weekly for 30-60 minutes) has a weak recommendation for prevention of both migraine and tension-type headache 1, 2
- Physical therapy delivered by a physical therapist has shown benefit for reducing headache frequency and intensity in both migraine and tension-type headache 1, 2
Treatment Selection for Mixed Headache Types
- For patients with both migraine and tension-type headache, amitriptyline may be more effective than propranolol 4
- Consider preventive therapy when patients have 4 or more migraine days per month or 2+ migraine days with significant disability despite appropriate acute therapy 1
- Start preventive medications at low doses and increase slowly until benefits are achieved without adverse effects 4
- Allow adequate trial periods (2-3 months) before determining efficacy of preventive treatments 4
Monitoring and Follow-up
- Monitor for medication overuse, which can worsen both headache types 1
- Evaluate for adverse effects of preventive medications, particularly anticholinergic effects with amitriptyline 2
- Consider tapering or discontinuing preventive medications after a period of stability 4
- Adjust treatment based on response, with consideration for combining therapies when single treatments are insufficient 4