What is the first-line treatment for recurrent headaches?

First-Line Treatment for Recurrent Headaches

The first-line treatment for recurrent headaches is non-steroidal anti-inflammatory drugs (NSAIDs), specifically aspirin, ibuprofen, naproxen sodium, and diclofenac potassium. 1, 2

Treatment Algorithm Based on Headache Type and Severity

For Mild to Moderate Headaches:

• NSAIDs with proven efficacy should be used as initial treatment, including:
  • Aspirin 1, 2
  • Ibuprofen 1, 2, 3
  • Naproxen sodium 1, 2
  • Diclofenac potassium 1
• The combination of acetaminophen plus aspirin plus caffeine is also effective as first-line therapy 1, 2
• Paracetamol (acetaminophen) alone has less efficacy and should only be used in patients who cannot tolerate NSAIDs 1, 4

For Moderate to Severe Headaches:

• If over-the-counter analgesics provide inadequate relief, triptans should be offered as second-line medication 1
• The American College of Physicians recommends adding a triptan to an NSAID for moderate to severe headaches that don't respond adequately to an NSAID alone (strong recommendation) 1
• All triptans have well-documented effectiveness, with evidence supporting:
  • Oral sumatriptan 1, 2, 5
  • Naratriptan 1, 2
  • Rizatriptan 1, 2
  • Zolmitriptan 1, 2

Special Considerations

For Headaches with Nausea/Vomiting:

• Select a non-oral route of administration when headaches present with significant nausea or vomiting 1, 2
• Options include:
  • Subcutaneous sumatriptan 1, 2
  • DHE nasal spray 1, 2
• Add an antiemetic to treat nausea, even if vomiting is not present 1, 2

Timing of Medication:

• Triptans are most effective when taken early in an attack, when headache is still mild 1
• Do not use triptans during the aura phase of a migraine attack 1

Medication Failures:

• If one triptan is ineffective, others might still provide relief 1
• When all other triptans have failed or in patients who rapidly reach peak headache intensity, sumatriptan by subcutaneous injection can be useful 1, 2
• For patients experiencing relapse (return of symptoms within 48 hours), repeating triptan treatment or combining with fast-acting NSAIDs may help 1

Important Cautions

• Repeated use of triptans increases the risk of medication overuse headache 1
• Doses of sumatriptan above 50 mg do not provide greater effect than 50 mg 5
• Triptans should be avoided in patients with cardiovascular disease due to their vasoconstrictive properties 6
• Paracetamol alone is statistically superior to placebo but has an inferior number needed to treat compared to other commonly used analgesics 4
• Ibuprofen provides pain relief in about half of migraine sufferers, with 400 mg being more effective than 200 mg 3

Third-Line Options

• If all available triptans fail or are contraindicated, alternatives include:
  • Ditans (lasmiditan) 1, 6
  • Gepants (ubrogepant, rimegepant) 1, 6
• These newer medications have limited availability but may be options for patients who cannot take triptans 1