What are the recommended as-needed (prn) medications for acute headache management?

Recommended PRN Medications for Acute Headache Management

For acute headache management, NSAIDs and acetaminophen should be used as first-line PRN medications, followed by triptans combined with NSAIDs or acetaminophen for moderate to severe headaches that don't respond to initial therapy. 1

First-Line PRN Options

• NSAIDs are recommended as first-line treatment for mild to moderate headaches due to their demonstrated efficacy and favorable tolerability profile 1, 2
• Specific effective NSAIDs include:
  • Aspirin (325-1000 mg) 1, 2
  • Ibuprofen (400-800 mg) 1, 3
  • Naproxen sodium (500-550 mg) 1, 2
• Acetaminophen (1000 mg) is effective for mild headaches but less effective than NSAIDs 4, 5
• Combination products containing acetaminophen, aspirin, and caffeine have demonstrated superior efficacy compared to single agents 1, 2

Second-Line PRN Options for Moderate to Severe Headaches

• For headaches that don't respond to NSAIDs or acetaminophen, add a triptan to an NSAID or acetaminophen 1, 6
• Triptans with good evidence include:
  • Sumatriptan (oral 25-100 mg, subcutaneous 6 mg, intranasal) 1
  • Rizatriptan (oral 5-10 mg) 1
  • Zolmitriptan (oral 2.5-5 mg) 1
  • Naratriptan (oral 1-2.5 mg) 1
• Non-oral routes (subcutaneous, intranasal) are preferred when significant nausea or vomiting is present 1, 6

Third-Line PRN Options

• For patients who don't respond to or cannot tolerate NSAIDs and triptans, consider:
  • CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant 1, 6
  • Dihydroergotamine (DHE) nasal spray 1
  • Lasmiditan (ditan) for those who don't respond to other treatments 1, 7

Important Considerations

• Begin treatment as early as possible after headache onset for improved efficacy 1, 6
• Patients who don't respond to one triptan may respond to another within the same drug class 1, 6
• Add an antiemetic (metoclopramide, prochlorperazine) when nausea and vomiting are present 1, 2
• Do not use opioids or butalbital-containing medications for routine headache treatment due to risk of dependency, rebound headaches, and eventual loss of efficacy 1, 2
• Limit acute therapy to no more than 2 days per week to prevent medication overuse headache 1
• Medication overuse headache can occur with frequent use of acute medications (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 1, 2

Contraindications and Cautions

• Triptans are contraindicated in patients with:
  • Ischemic vascular conditions 1, 6
  • Uncontrolled hypertension 1, 6
  • Significant cardiovascular disease 1, 6
  • Basilar or hemiplegic migraine 6, 2
• NSAIDs should be used with caution in patients with renal impairment, history of GI bleeding, or heart disease 2
• For pregnant or breastfeeding patients, discuss the adverse effects of medications during pregnancy and lactation 1, 6

When to Consider Preventive Therapy

• If episodic headaches occur frequently (≥2 attacks/month) or treatment doesn't provide adequate response, consider preventive medications 1, 6
• Preventive therapy is indicated when acute medications are used more than twice weekly 1, 8