What are the recommended treatments for headaches?

Recommended Treatments for Headaches

For the treatment of headaches, a combination of a triptan with an NSAID or acetaminophen is recommended as first-line therapy for moderate to severe migraine attacks, while NSAIDs or acetaminophen alone are recommended for mild to moderate headaches. 1

Headache Classification and Treatment Algorithm

Migraine Headache Treatment

• First-line for mild to moderate migraine:

  • Acetaminophen (1000 mg), aspirin, ibuprofen (400 mg), or naproxen 1
  • Begin treatment as soon as possible after onset for maximum efficacy 1

• First-line for moderate to severe migraine:

  • Combination therapy: triptan plus NSAID or acetaminophen 1
  • Triptans (sumatriptan, rizatriptan, zolmitriptan) have demonstrated efficacy with pain freedom at 2 hours 2

• Second-line options (for those who don't respond to or tolerate first-line therapy):

  • CGRP antagonists-gepants (rimegepant, ubrogepant, zavegepant) 1
  • Ergot alkaloid (dihydroergotamine) 1
  • Consider lasmiditan only after failure of all other options 1

• For migraine with severe nausea/vomiting:

  • Use non-oral route of administration (subcutaneous sumatriptan, intranasal zolmitriptan) 1
  • Add antiemetic medication 1, 3

Tension-Type Headache Treatment

• Acute treatment:

  • Ibuprofen 400 mg or acetaminophen 1000 mg 1, 3
  • NSAIDs generally provide better relief than acetaminophen 4

• Preventive treatment (for chronic tension-type headache):

  • Amitriptyline (30-150 mg/day) 1, 3, 5

Cluster Headache Treatment

• Acute treatment:

  • Subcutaneous sumatriptan (6 mg) or intranasal zolmitriptan (10 mg) 1, 3
  • Normobaric oxygen therapy 1

• Preventive treatment:

  • Galcanezumab for episodic cluster headache (not recommended for chronic cluster headache) 1, 3

Important Considerations

• Avoid these medications:

  • Opioids and butalbital-containing medications should NOT be used for migraine treatment due to risk of dependence and medication overuse headache 1, 3

• Medication overuse headache risk:

  • Defined as headache occurring ≥15 days/month for ≥3 months due to overuse of acute medications 1
  • Threshold varies by medication: ≥15 days/month with NSAIDs; ≥10 days/month with triptans 1

• Non-pharmacologic approaches:

  • Lifestyle modifications are important: hydration, regular meals, sufficient sleep, physical activity, stress management 1
  • Greater occipital nerve block may be considered for short-term migraine treatment 1

• Special populations:

  • In pregnant patients or those of childbearing potential, discuss risks of medications during pregnancy and lactation 1
  • For elderly patients or those with cardiovascular risk factors, use caution with triptans and consider NSAIDs or acetaminophen 6, 7

Efficacy Comparisons

• Ibuprofen 400 mg provides pain relief in about 57% of migraine sufferers at 2 hours (vs. 25% with placebo) 4
• Acetaminophen 1000 mg provides pain relief in about 56% of migraine sufferers at 2 hours (vs. 36% with placebo) 6
• Sumatriptan 100 mg provides headache response in 61-62% of patients at 2 hours 2
• Combination therapy (triptan + NSAID/acetaminophen) is more effective than monotherapy 1

Common Pitfalls to Avoid

• Delayed treatment: Starting treatment early improves efficacy; counsel patients to begin treatment as soon as possible after headache onset 1
• Inadequate dosing: Using suboptimal doses of medications (e.g., acetaminophen <1000 mg, ibuprofen <400 mg) may lead to treatment failure 6, 4
• Overuse of acute medications: Can lead to medication overuse headache; limit use of triptans to <10 days/month and NSAIDs to <15 days/month 1
• Failure to address nausea/vomiting: Consider non-oral routes or add antiemetics when nausea/vomiting are prominent 1, 3
• Not considering preventive therapy: Consider preventive medications when attacks are frequent (≥2/month with disability), when acute treatments fail, or when acute medications are used >2 days/week 1