What is the recommended treatment for acute, non-emergent headache in a clinic setting?

Treatment of Acute, Non-Emergent Headache in Clinic

For acute, non-emergent headache in a clinic setting, first-line treatment should be an NSAID (such as ibuprofen, naproxen, diclofenac, or aspirin) or acetaminophen, with combination therapy of a triptan plus an NSAID or acetaminophen recommended for moderate to severe headaches. 1

First-Line Treatment Options

• For mild headaches, consider an NSAID, acetaminophen, or the combination of an NSAID and acetaminophen 1, 2
• Recommended NSAIDs with proven efficacy include:
  • Ibuprofen 400-600 mg every 6 hours (maximum 2400 mg daily) 2, 3
  • Naproxen 500 mg initially, then 250 mg every 6-8 hours (maximum 1250 mg daily) 2
  • Diclofenac potassium (dose based on formulation) 1
  • Aspirin 500-1000 mg every 4-6 hours (maximum 4000 mg daily) 2
• Acetaminophen 1000 mg every 6 hours (maximum 4000 mg daily) if NSAIDs are contraindicated 2, 4

Treatment for Moderate to Severe Headache

• For moderate to severe headache, add a triptan to an NSAID or acetaminophen 1, 5
• Begin treatment as soon as possible after headache onset for maximum efficacy 1, 5
• If one triptan is ineffective, another triptan may still provide relief 1
• For patients with severe nausea or vomiting, consider using a non-oral triptan and an antiemetic 1

Second-Line Treatment Options

• For patients who do not tolerate or have inadequate response to combination therapy of a triptan and an NSAID/acetaminophen, consider CGRP antagonists-gepants (rimegepant, ubrogepant, or zavegepant) or dihydroergotamine 1, 5
• The ditan lasmiditan may be considered for patients who do not respond to all other pharmacologic treatments 1

Important Considerations

• Avoid opioids and butalbital for the treatment of acute headache 1, 2
• Be aware of medication overuse headache, which can occur with frequent use of acute medications (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 1
• Patients who do not respond adequately to acute treatment may benefit from preventive medications 1
• Soluble formulations of NSAIDs may provide more rapid relief than standard tablets 3

Lifestyle Modifications

• Recommend lifestyle modifications including:
  • Staying well hydrated and maintaining regular meals 1, 5
  • Ensuring sufficient and consistent sleep 1, 5
  • Engaging in regular physical activity, preferably moderate to intense aerobic exercise 1, 5
  • Managing stress with relaxation techniques or mindfulness practices 1, 5
  • Pursuing weight loss for those who are overweight or obese 1, 5
  • Identifying and avoiding personal headache triggers 1, 5

Treatment Algorithm

1. For mild headache:

   • Start with an NSAID (ibuprofen, naproxen, diclofenac, or aspirin) 1
   • If NSAIDs are contraindicated, use acetaminophen 2

2. For moderate to severe headache:

   • Use combination therapy of a triptan plus an NSAID or acetaminophen 1, 5
   • If the first triptan is ineffective, try another triptan 1

3. For patients who don't respond to above treatments:

   • Consider CGRP antagonists-gepants or dihydroergotamine 1
   • Consider lasmiditan as a last resort 1

4. For patients with significant nausea/vomiting:

   • Use a non-oral triptan and add an antiemetic 1

Pitfalls and Caveats

• Avoid prescribing opioids or butalbital-containing medications, as they can lead to dependency, rebound headaches, and eventual loss of efficacy 1, 2
• Be cautious with triptans in patients with cardiovascular disease due to their vasoconstrictive properties 6
• Monitor for medication overuse headache, especially with frequent use of acute treatments 1
• Consider cost when prescribing medications, as less expensive recommended medications may be equally effective 1