What is the best analgesia for controlling headaches?

Best Analgesia for Controlling Headache

NSAIDs are the first-line treatment for controlling headaches due to their demonstrated efficacy and favorable tolerability profile. 1

First-Line Treatment Options Based on Headache Type and Severity

Mild to Moderate Headaches

• NSAIDs are recommended as first-line treatment for mild to moderate headaches, including both migraine and tension-type headaches 2, 1
• Specific effective NSAIDs include:
  • Aspirin (650-1000mg) 2, 1
  • Ibuprofen (400-600mg) 2, 1
  • Naproxen sodium (500-550mg) 2, 1
  • Combination of acetaminophen, aspirin, and caffeine 1, 3
• Acetaminophen (1000mg) alone is effective for tension-type headaches but less effective than NSAIDs for migraines 4, 5

Moderate to Severe Headaches

• Triptans (serotonin 1B/1D agonists) are recommended as first-line therapy for moderate to severe migraine attacks 1, 6
• Effective triptan options include:
  • Oral naratriptan, rizatriptan, sumatriptan, and zolmitriptan 2, 1
  • Subcutaneous and intranasal sumatriptan for patients with nausea and vomiting 1, 7
• Sumatriptan 100mg has shown significant efficacy with 56-62% of patients achieving headache relief at 2 hours compared to 17-27% with placebo 7

Second-Line and Rescue Treatments

• Antiemetics, particularly intravenous metoclopramide (10mg), may be appropriate as monotherapy for acute attacks, especially when nausea and vomiting are present 2, 1
• Intranasal dihydroergotamine (DHE) has good evidence for efficacy and safety as monotherapy for acute migraine attacks 2, 1
• Combination therapy of a triptan and an NSAID has shown better efficacy than either medication alone 6
• For intravenous treatment in urgent care settings, a combination of ketorolac (30mg IV), metoclopramide (10mg IV), and prochlorperazine (10mg IV) is effective 1

Important Considerations and Cautions

• Medication-overuse headache can result from frequent use of acute medications (more than twice weekly), leading to increasing headache frequency 1, 4
• Treatment should begin as early as possible during an attack to improve efficacy 1, 8
• Opioids should be reserved for when other medications cannot be used, when sedation effects are not a concern, or when the risk for abuse has been addressed 2, 1
• Triptans are contraindicated in patients with risk for heart disease, basilar or hemiplegic migraine, or uncontrolled hypertension 2, 1
• For patients with chronic headaches (≥15 headache days per month), preventive treatment should be considered rather than relying solely on abortive medications 4, 8

Treatment Algorithm

1. For mild to moderate tension-type headaches:

   • Start with ibuprofen 400mg or acetaminophen 1000mg 4, 5
   • If inadequate response, try combination of acetaminophen, aspirin, and caffeine 1, 3

2. For mild to moderate migraines:

   • Start with NSAIDs (ibuprofen, naproxen, or aspirin) 2, 1
   • Add an antiemetic if nausea is present 1, 8

3. For moderate to severe migraines:

   • Use triptans (sumatriptan, rizatriptan, zolmitriptan, or naratriptan) 2, 1, 7
   • Consider combination therapy with NSAID plus triptan for enhanced efficacy 6

4. For severe, refractory headaches requiring IV treatment:

   • Ketorolac 30mg IV plus metoclopramide 10mg IV is recommended as first-line combination therapy 1
   • Prochlorperazine 10mg IV is an effective alternative 1
   • Dihydroergotamine (DHE) can be considered for patients with contraindications to NSAIDs 1