What are the treatment options for frontal headaches?

Treatment Options for Frontal Headaches

For frontal headaches, first-line treatment should include NSAIDs such as aspirin, ibuprofen, or naproxen sodium, which are effective for mild to moderate migraine attacks. 1

First-Line Treatment Options

• NSAIDs with proven efficacy (aspirin 650-1000mg, ibuprofen 400-800mg, naproxen sodium 275-550mg) are recommended as first-line therapy for mild to moderate frontal headaches 1
• Acetaminophen alone has limited efficacy for migraine treatment but may be used for those who cannot tolerate NSAIDs 1, 2
• Combination analgesics containing caffeine (such as aspirin plus acetaminophen plus caffeine) show better efficacy than single agents alone 1
• For moderate to severe headaches, triptans (sumatriptan, naratriptan, rizatriptan, zolmitriptan) are recommended as first-line treatments 1

Treatment Algorithm Based on Headache Severity

For Mild to Moderate Frontal Headaches:

• Start with NSAIDs (aspirin, ibuprofen, naproxen sodium) 1, 3
• Ibuprofen 400mg provides better pain relief than 200mg, with NNTs of 3.2 for 2-hour headache relief 4
• Soluble formulations of ibuprofen provide more rapid relief than standard tablets 4
• If inadequate response within 2 hours, escalate to a triptan 1

For Moderate to Severe Frontal Headaches:

• The American College of Physicians strongly recommends adding a triptan to an NSAID for moderate to severe migraine headaches that don't respond adequately to an NSAID alone 1
• Subcutaneous sumatriptan is most effective when oral medications aren't effective or when patients rapidly reach peak headache intensity 1
• Triptans are most effective when taken early in an attack while the headache is still mild 1

Adjunctive Therapy

• Antiemetics such as metoclopramide (Reglan) or prochlorperazine (Compazine) should be added to treat accompanying nausea and improve gastric motility 1, 5
• Prochlorperazine can effectively relieve headache pain in addition to treating nausea 1
• Caffeine can be used as an adjunctive therapy for synergistic analgesia 1
• Sleep can be an effective non-pharmacological adjunctive therapy 1

For Headaches with Significant Nausea/Vomiting:

• Select a non-oral route of administration (subcutaneous or nasal spray) 1, 5
• Add an antiemetic such as metoclopramide or prochlorperazine 1, 5
• Paracetamol 1000mg plus metoclopramide 10mg has shown efficacy equivalent to oral sumatriptan 100mg 2

For Status Migrainosus (Prolonged, Severe Headache):

• Systemic corticosteroids are the treatment of choice 6
• Ketorolac (Toradol), a parenteral NSAID, has a relatively rapid onset of action and six-hour duration 1, 6
• Opioid analgesics such as meperidine (Demerol) or butorphanol (Stadol) should be reserved for severe cases that don't respond to other treatments 1, 6

Important Considerations and Cautions

• Avoid overuse of analgesics as this may lead to rebound headaches 1
• Limit and carefully monitor the use of opioids and butalbital-containing analgesics due to risk of dependency and rebound headaches 1, 6
• Triptans should be avoided in patients with cardiovascular disease 5
• If one triptan is ineffective, others might still provide relief 1
• Acetaminophen alone provides statistically superior relief compared to placebo but has an NNT of 12 for pain-free response at two hours, which is inferior to other commonly used analgesics 2, 7

Preventive Considerations

• For patients with frequent attacks, consider preventive medications such as β-blockers (propranolol, timolol), antidepressants (amitriptyline), or anticonvulsants (divalproex sodium, sodium valproate) 1
• Lifestyle modifications addressing predisposing factors like poor sleep quality or physical fitness may help reduce attack frequency 1