What are the guidelines for managing migraines and tension-type headaches?

Guidelines for Managing Migraines and Tension-Type Headaches

For effective management of migraines and tension-type headaches, NSAIDs should be used as first-line treatment for acute attacks, while preventive therapy should be considered for patients with frequent headaches causing significant disability. 1

Diagnosis and Classification

• Migraine headaches are characterized by at least two of the following: unilateral location, throbbing character, moderate to severe intensity, worsening with activity; plus either nausea/vomiting or photophobia/phonophobia 1
• Tension-type headaches present with at least two of these features: pressing/tightening (non-pulsatile) character, mild to moderate intensity, bilateral location, no aggravation with routine activity; plus absence of nausea/vomiting 1
• Overlapping symptoms between migraine and tension-type headache are common, making misdiagnosis possible; rigid adherence to diagnostic criteria may lead to inappropriate treatment 2

Acute Treatment for Migraine

First-Line Options

• NSAIDs are recommended as first-line treatment for most migraine patients 1
• Evidence supports efficacy of aspirin, ibuprofen, naproxen sodium, and acetaminophen-aspirin-caffeine combinations 1
• Acetaminophen alone is ineffective for migraine 1

Second-Line Options

• Triptans (serotonin-1B/1D agonists) should be used when NSAIDs are ineffective 1
• Sumatriptan, rizatriptan, zolmitriptan, and naratriptan have good evidence for efficacy 1
• Sumatriptan dosing: 25mg, 50mg, or 100mg orally; 50mg and 100mg may provide greater effect than 25mg; maximum daily dose is 200mg in 24 hours 3
• Contraindications for triptans include uncontrolled hypertension, basilar or hemiplegic migraine, and risk for heart disease 1

Additional Options

• Dihydroergotamine (DHE) intranasally has good evidence for efficacy and safety 1
• Butorphanol nasal spray has good evidence for efficacy 1
• Antiemetics should be used when nausea is a significant component 1
• Non-oral routes of administration should be selected when nausea/vomiting are early symptoms 1

Acute Treatment for Tension-Type Headache

• Ibuprofen 400mg or acetaminophen 1000mg are first-line options for acute treatment 4
• Both medications show significant improvement in pain-free response at 2 hours 4
• Combination analgesics with caffeine can be considered for inadequate relief 5
• Limit use of acute medications to no more than 2 days per week to prevent medication overuse headache 4

Preventive Treatment for Migraine

Indications for Prevention

• Two or more migraine attacks per month with disability lasting ≥3 days per month 1
• Use of rescue medication more than twice weekly 1
• Failure of or contraindications to acute treatments 1
• Presence of uncommon migraine conditions (prolonged aura, migrainous infarction, hemiplegic migraine) 1

First-Line Preventive Agents

• Propranolol (80-240mg daily) 1
• Timolol (20-30mg daily) 1
• Amitriptyline (30-150mg daily) 1
• Divalproex sodium (500-1,500mg daily) 1
• Sodium valproate (800-1,500mg daily) 1

Treatment Approach

• Start with low doses and increase slowly until benefits are achieved without adverse effects 1
• Allow 2-3 months for clinical benefits to become apparent 1
• Consider tapering or discontinuing after a period of stability 1
• Propranolol is superior for pure migraine, while amitriptyline is more effective for mixed migraine and tension-type headache 1

Preventive Treatment for Tension-Type Headache

• Amitriptyline is recommended for prevention of chronic tension-type headache 4
• Starting doses typically range from 10-25mg at bedtime, with gradual titration to 50-100mg as needed 4
• Monitor for anticholinergic side effects including weight gain, drowsiness, and dry mouth 1, 4
• Valproate may be considered as an alternative preventive option 5

Medication Overuse Considerations

• Limit acute headache medications to no more than twice weekly to prevent medication-overuse headaches 1
• Consider preventive therapy if medication overuse is suspected or at risk 1
• Be vigilant for rebound headaches associated with withdrawal of analgesics or abortive medications 1
• Opioids should be avoided for tension-type headache due to risk of dependence and medication overuse 4

Non-Pharmacological Approaches

• Physical therapy and aerobic exercise are recommended as adjunctive management options 4
• Biofeedback, relaxation training, self-hypnosis, and cognitive therapy may be beneficial 6
• Lifestyle modifications including regular meals, adequate hydration, improved sleep hygiene, and stress management techniques are important 4

Special Considerations

• Greater occipital nerve blocks may provide short-term relief for refractory headaches 5
• Botulinum toxin injections are not recommended for chronic tension-type headache prevention 5
• Evaluate for comorbidities, including psychiatric disorders and sleep disturbances, which may affect treatment response 5
• Track headache frequency, severity, duration, disability, treatment response, and adverse effects using a daily diary 1