What are the guidelines for managing headaches in primary care?

From the Guidelines

Primary care management of headaches should prioritize a two-pronged approach for migraines, including acute treatment and preventive therapy, with consideration of lifestyle modifications and patient education, as recommended by the most recent guidelines 1. The management of headaches in primary care involves distinguishing between primary headaches, such as tension, migraine, or cluster headaches, and secondary headaches caused by underlying conditions.

• For acute treatment of migraines, consider NSAIDs, triptans (such as sumatriptan 50-100mg orally at onset, maximum 200mg/day), or combination medications.
• For preventive therapy, use beta blockers (atenolol, bisoprolol, metoprolol or propranolol), topiramate or candesartan as first-line medications, as recommended by the 2021 guidelines 1.
• Lifestyle modifications are essential for all headache types, including regular sleep patterns, stress management, hydration, and trigger avoidance.
• Patients should maintain headache diaries to identify patterns and triggers, and patient education about realistic expectations and the chronic nature of many headache disorders improves treatment adherence and outcomes. Key considerations in managing headaches include:
• Red flags requiring immediate referral, such as sudden-onset severe headache, headache with fever or neurological symptoms, new headache in patients over 50, or headaches worsening with position changes.
• Medication overuse headache, which should be considered in patients using analgesics more than 10-15 days monthly, requiring gradual withdrawal of the overused medication, as noted in earlier guidelines 1. Overall, the goal of headache management in primary care is to reduce morbidity, mortality, and improve quality of life, with a focus on preventive therapy and lifestyle modifications, as supported by the most recent and highest quality evidence 1.

From the FDA Drug Label

Before treating headaches in patients not previously diagnosed as migraineurs, and in migraineurs who present with atypical symptoms, exclude other potentially serious neurological conditions.

The guidelines for managing headaches in primary care include excluding other potentially serious neurological conditions before treating headaches in patients not previously diagnosed as migraineurs, and in migraineurs who present with atypical symptoms 2.

• Key considerations include:
  • Evaluating patients for cardiovascular risk factors
  • Monitoring blood pressure
  • Being aware of the potential for cerebrovascular events, serotonin syndrome, and anaphylactic reactions
  • Considering medication overuse headache in patients taking acute migraine drugs for 10 or more days per month 2.

From the Research

Guidelines for Managing Headaches in Primary Care

• The majority of children who suffer from recurrent headaches can be effectively treated in the primary health care 3
• For childhood migraine, paracetamol and ibuprofen are the recommended medications 3
• Triptans are the first-line treatment for moderate-to-severe migraine headaches 4
• Sumatriptan formulations have different pharmacokinetic, efficacy, and adverse event profiles, and patients should use an attack-based treatment approach for their migraine attacks to balance the speed of relief, efficacy, and tolerability 4

Treatment Options for Acute Migraine Attacks

• Migraine-specific triptans and migraine-nonspecific nonsteroidal antiinflammatory drugs (NSAIDs) have the best levels of evidence, and are recommended as the first-line medications for acute migraine attacks 5
• Acute medications can be organized into four treatment strategies for use in various clinical settings, including the acetaminophen-NSAID strategy, the triptan strategy, the refractory migraine strategies, and strategies for patients with contraindications to vasoconstricting drugs 6
• The administration of acute medications should follow the concept of "stratified care", with oral NSAIDs as the first choice for mild to moderate migraine attacks, and oral or nasal spray triptans and ergotamine/caffeine compounds recommended for moderate to severe attacks 5

Preventive Therapy for Migraine

• Lifestyle modifications and migraine trigger avoidance are recommended as preventive measures for all individuals with migraine 7
• The decision to recommend additional migraine preventive therapy should consider the frequency of migraine attacks and headaches, extent of migraine-associated disability, frequency of using acute migraine treatments and the responsiveness to such treatments, and patient preferences 7
• Treatments with the most favorable profiles for preventive therapy include amitriptyline, beta-blockers, biofeedback, candesartan, coenzyme Q10, cognitive-behavioral therapy, magnesium citrate, onabotulinumtoxinA, relaxation therapy, riboflavin, and topiramate 7