What is the recommended medication cocktail in the emergency department (ED) for immediate relief from tension and headache?

Emergency Department Medication Cocktail for Tension Headache Relief

For immediate relief of tension headache in the emergency department, use ibuprofen 400-600 mg orally or acetaminophen 1000 mg orally as first-line treatment, with the addition of an antiemetic if nausea is present. 1, 2

First-Line Medications for Tension Headache

• Ibuprofen 400-600 mg orally every 4-6 hours is recommended as a first-line treatment for tension headache 1, 2
• Acetaminophen 1000 mg orally is an alternative first-line option with similar efficacy 1, 2, 3
• NSAIDs have been shown to have a longer time to re-medication with a safer side effect profile compared to codeine-acetaminophen combinations 1
• For patients with significant nausea, add metoclopramide 10-20 mg orally or prochlorperazine to provide relief from nausea and enhance absorption of analgesics 1, 4

Treatment Algorithm

1. Initial Assessment:

   • Determine if headache is tension-type (bilateral, pressing/tightening quality, mild to moderate intensity) 2
   • Assess for presence of nausea or vomiting 1

2. First-Line Treatment:

   • Administer ibuprofen 400-600 mg orally OR acetaminophen 1000 mg orally 1, 2
   • If nausea is present, add metoclopramide 10-20 mg or prochlorperazine 1

3. If Inadequate Response After 1-2 Hours:

   • Consider alternative NSAID (naproxen, diclofenac, ketorolac) 1, 5
   • For severe cases unresponsive to oral medications, consider intravenous options:
     • IV ketorolac (parenteral NSAID) for severe tension headaches 1
     • IV paracetamol 1000 mg has shown efficacy similar to IV dexketoprofen 6

Special Considerations

• Avoid codeine-acetaminophen combinations as NSAIDs have been shown to be superior with fewer side effects 1
• Limit use of opioid analgesics like meperidine and butorphanol to severe cases unresponsive to first-line treatments, as they can lead to dependency and rebound headaches 1
• If using IV medications, the Critical Care guidelines suggest a protocol of hydromorphone 1 mg + 1 mg for severe pain unresponsive to other treatments 1
• For patients with frequent tension headaches, consider preventive treatment with amitriptyline rather than repeated acute medications 2

Pitfalls and Caveats

• Overuse of analgesics (>10-15 days per month) can lead to medication-overuse headache, which is difficult to treat 2
• Ensure the headache is truly tension-type and not migraine, as treatment approaches differ 2
• Avoid botulinum toxin injections for tension-type headache as they are not recommended and should be avoided 2
• Sedatives like barbiturates are no longer widely recommended for headache therapy due to the availability of more effective nonsedating agents 1
• For migraine misdiagnosed as tension headache, triptans like sumatriptan would be more effective than simple analgesics 1, 7