What is the recommended acute management of headache?

Acute Management of Headache

For acute headache management, NSAIDs should be used as first-line treatment for mild to moderate migraine attacks, while triptans should be added to NSAIDs or acetaminophen for moderate to severe migraines or when NSAIDs alone are ineffective. 1, 2

First-Line Treatment Options

• NSAIDs (aspirin, ibuprofen, naproxen sodium, diclofenac potassium) are recommended as first-line therapy for mild to moderate migraine attacks due to their demonstrated efficacy and favorable tolerability profile 2, 3
• Treatment should begin as early as possible during an attack for maximum efficacy 2, 3
• Combination therapy of acetaminophen plus aspirin plus caffeine is effective for migraine treatment, but acetaminophen alone is not recommended for migraine 2, 1
• For patients with nausea and vomiting, add metoclopramide (10 mg) or prochlorperazine (10 mg) to treat these symptoms and provide synergistic analgesia 3, 1

Second-Line Treatment Options

• Triptans (sumatriptan, rizatriptan, naratriptan, zolmitriptan) should be added to NSAIDs or acetaminophen when first-line treatments are ineffective for moderate to severe migraines 1, 2
• Subcutaneously injectable sumatriptan reaches peak blood concentrations in approximately 15 minutes and has been shown to be effective in 70-82% of patients 1
• If one triptan is ineffective, try a different triptan as patients may respond differently to various triptans 1, 2
• For patients with severe nausea or vomiting, consider non-oral triptans (subcutaneous, intranasal) or adding an antiemetic 2, 3

Third-Line Treatment Options

• For patients who fail all available triptans or have contraindications to their use, consider CGRP antagonists-gepants (rimegepant, ubrogepant, zavegepant) or dihydroergotamine 1, 2
• Dihydroergotamine (DHE) has good evidence for efficacy and safety as monotherapy for acute migraine attacks, particularly for refractory cases 3

Important Considerations and Cautions

• Avoid opioids and butalbital-containing medications for treating acute migraine headaches due to risk of dependency, medication overuse headache, and eventual loss of efficacy 1, 2, 3
• Be aware of medication overuse headache risk when acute treatments are used too frequently (≥15 days/month with NSAIDs or ≥10 days/month with triptans) 1, 2
• Triptans are contraindicated in patients with ischemic vascular conditions, vasospastic coronary disease, uncontrolled hypertension, or other significant cardiovascular disease 1
• Ketorolac (Toradol), a parenteral NSAID, has a relatively rapid onset of action and approximately six hours of duration, making it ideal for severe migraine abortive therapy in emergency or urgent care settings 3, 1

Evidence-Based Treatment Algorithm

1. For mild to moderate headache:

   • Start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-550 mg, or aspirin 900-1000 mg) 2, 4
   • If ineffective, add a triptan (sumatriptan 50-100 mg, rizatriptan 10 mg) 1, 5

2. For moderate to severe headache:

   • Start with a triptan plus NSAID or acetaminophen combination 1, 2
   • Sumatriptan 100 mg has demonstrated efficacy with 62% of patients achieving headache response at 2 hours compared to 27% with placebo 5

3. For headache with significant nausea/vomiting:

   • Use non-oral routes (subcutaneous sumatriptan, intranasal triptans) 1, 2
   • Add antiemetics (metoclopramide 10 mg or prochlorperazine 10 mg) 3, 1

4. For refractory headache:

   • Consider dihydroergotamine or CGRP antagonists-gepants 1, 3
   • Avoid opioids and butalbital-containing medications 1, 2

By following this evidence-based approach to acute headache management, clinicians can effectively treat headaches while minimizing adverse effects and preventing medication overuse headache.