What is the treatment for an acute intractable headache?

Treatment for Acute Intractable Headache

For acute intractable headache, the first-line treatment is combination therapy with a triptan and an NSAID or acetaminophen, which should be initiated as early as possible after headache onset to maximize efficacy. 1

First-Line Treatment Options Based on Headache Severity

For Mild to Moderate Headache:

• Start with NSAIDs such as aspirin, ibuprofen, naproxen sodium, or diclofenac potassium 1
• Acetaminophen alone has less efficacy and should only be used in patients who cannot tolerate NSAIDs 1
• Combination products containing acetaminophen, aspirin, and caffeine are also effective 2, 3

For Moderate to Severe Headache:

• Use combination therapy with a triptan plus an NSAID or acetaminophen for improved efficacy 1
• Triptans (sumatriptan, rizatriptan, eletriptan, zolmitriptan) are highly effective for moderate to severe attacks 1, 4
• If one triptan is ineffective, try another as individual responses vary 1
• For rapid relief, consider subcutaneous sumatriptan which has the fastest onset of action 1, 4

For Patients with Significant Nausea/Vomiting:

• Use non-oral routes of administration (subcutaneous, intranasal) 1, 2
• Add an antiemetic such as metoclopramide or prochlorperazine which also provides synergistic analgesia 1, 2

Second-Line Options (for patients who fail first-line therapy):

• CGRP antagonists-gepants (rimegepant, ubrogepant, zavegepant) 1
• Dihydroergotamine (DHE), particularly the intranasal formulation 1
• Ditan lasmiditan for patients who have failed all other treatments 1

Important Cautions and Considerations:

• DO NOT use opioids or butalbital-containing medications for acute migraine treatment 1
• Be aware of medication overuse headache risk: limit acute treatments to no more than twice weekly 1
• The threshold for medication overuse headache varies by treatment (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 1
• Triptans are contraindicated in patients with coronary artery disease, Prinzmetal's angina, uncontrolled hypertension, and history of stroke or TIA 4
• Monitor for serotonin syndrome when triptans are used concurrently with SSRIs, SNRIs, or MAO inhibitors 4

For Intractable Headache Requiring IV Treatment:

• IV metoclopramide (10 mg) plus IV ketorolac (30 mg) is an effective first-line combination 2
• IV prochlorperazine (10 mg) is comparable to metoclopramide in efficacy 2
• For status migrainosus (prolonged, severe migraine), consider systemic corticosteroids 3

Lifestyle Modifications to Recommend:

• Stay well hydrated and maintain regular meals 1
• Ensure sufficient and consistent sleep 1
• Engage in regular physical activity, preferably moderate to intense aerobic exercise 1
• Manage stress with relaxation techniques or mindfulness practices 1
• Pursue weight loss if overweight or obese 1

Remember that early treatment is crucial for optimal efficacy, and patients should be counseled to begin treatment as soon as possible after headache onset 1.