What are the different treatments for headaches?

Treatment Options for Different Types of Headaches

For the treatment of headaches, NSAIDs and acetaminophen are first-line treatments for mild to moderate headaches, while triptans are recommended for moderate to severe migraine attacks. 1, 2

Migraine Headache Treatment

First-Line Options

• For mild to moderate migraine attacks, use NSAIDs (ibuprofen 400-800mg, naproxen sodium 275-550mg) or acetaminophen (1000mg) 1, 2
• For moderate to severe migraine attacks, use a triptan (sumatriptan, rizatriptan, zolmitriptan) combined with an NSAID or acetaminophen 1
• Begin treatment as soon as possible after headache onset for maximum efficacy 1, 2
• For patients with significant nausea/vomiting, consider non-oral routes such as intranasal or subcutaneous triptans 2, 3

Second-Line Options

• For patients who don't tolerate or respond inadequately to first-line treatments, consider CGRP antagonists-gepants (rimegepant, ubrogepant, zavegepant) or dihydroergotamine 1
• The ditan lasmiditan can be considered when patients don't respond to all other treatments 1
• Antiemetics (metoclopramide, prochlorperazine) can be effective for migraine with prominent nausea 2

Important Cautions

• Do not use opioids or butalbital-containing medications for migraine treatment 1, 2
• Be aware of medication overuse headache risk (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 1
• Triptans should be avoided in patients with cardiovascular disease due to their vasoconstrictive properties 3, 4

Tension-Type Headache Treatment

First-Line Options

• Ibuprofen (400mg) or acetaminophen (1000mg) are recommended for acute tension-type headache 1
• Note that lower doses of acetaminophen (500-650mg) have not shown significant improvement 1

Preventive Treatment

• Amitriptyline at 50mg or 100mg is recommended for preventive treatment of chronic tension-type headache 1
• Be cautious with anticholinergic side effects, especially in older patients or those with cardiac conditions 1
• OnabotulinumtoxinA is not recommended for chronic tension-type headache 1

Concussion-Related Headache Treatment

First-Line Options

• Ibuprofen (400-800mg every 6 hours) is recommended as first-line treatment 5
• Naproxen sodium (275-550mg every 2-6 hours) is an alternative with longer duration 5
• Avoid aspirin in children and adolescents due to risk of Reye's syndrome 5

Second-Line Options

• Acetaminophen (1000mg) can be used for patients who cannot tolerate NSAIDs 5
• Aspirin-acetaminophen-caffeine combinations are recommended for migraine-like post-concussion headaches 5

Urgent Care/Emergency Treatment

IV/IM Treatment Options

• For severe headaches requiring parenteral treatment, ketorolac (30-60mg IM/IV) is effective 2
• Metoclopramide (10mg IV) or prochlorperazine (10mg IV) are effective for both pain and nausea 2
• Combination therapy with IV metoclopramide plus IV ketorolac is recommended for severe migraine attacks 2
• Dihydroergotamine (DHE) is an alternative for patients with contraindications to NSAIDs 2

Non-Pharmacologic Approaches

Behavioral and Physical Interventions

• Physical therapy using thermal methods, trigger point massage, and mobilization techniques can be beneficial for migraine and tension-type headache 1
• Aerobic exercise or progressive strength training (2-3 times weekly for 30-60 minutes) is recommended for prevention of both migraine and tension-type headache 1
• Evidence is insufficient to recommend for or against biofeedback, cognitive behavioral therapy, mindfulness-based therapies, and progressive muscle relaxation when used alone 1

Important Considerations for All Headache Types

• Lifestyle modifications are important: hydration, regular meals, sufficient sleep, physical activity, stress management 1
• Avoid medication overuse (>2 days/week) to prevent medication overuse headache 2, 5
• Consider cost when prescribing medications; NSAIDs and acetaminophen are generally less expensive than triptans or newer agents 6, 7
• Treatment should be individualized based on headache severity, associated symptoms, and patient response 2, 6

The evidence strongly supports using NSAIDs and acetaminophen as first-line treatments for mild to moderate headaches, with triptans for moderate to severe migraines. Combination therapy often provides better relief than monotherapy. Newer agents like gepants and ditans should be reserved for those who fail first-line treatments due to their higher cost and limited comparative evidence.