What is the treatment for cannabis-induced headache or migraine?

Treatment of Cannabis-Induced Headache/Migraine

Treat cannabis-induced headache or migraine with standard acute migraine therapy, starting with NSAIDs as first-line treatment, followed by triptans for moderate-to-severe cases, while discontinuing cannabis use to prevent medication-overuse headache.

First-Line Treatment Approach

NSAIDs as Initial Therapy

• Start with NSAIDs for mild to moderate cannabis-induced headache, using the same agents proven effective for primary migraine 1, 2
• Specific dosing recommendations include aspirin 650-1000 mg, ibuprofen 400-800 mg, or naproxen sodium 275-550 mg 2, 3
• Combination therapy with aspirin plus acetaminophen plus caffeine shows enhanced efficacy compared to single agents 1, 3
• Ketorolac 30-60 mg IM/IV provides rapid onset (approximately 6 hours duration) for severe presentations requiring parenteral therapy 2

Escalation to Migraine-Specific Agents

• If NSAIDs fail within 2 hours, escalate to triptans (naratriptan, rizatriptan, sumatriptan, or zolmitriptan) for moderate-to-severe headache 1, 2, 3
• Subcutaneous sumatriptan is most effective when rapid peak intensity occurs or oral medications are ineffective 3
• Triptans work best when administered early while headache remains mild 3
• Intranasal dihydroergotamine (DHE) serves as an alternative migraine-specific agent with good efficacy and safety profile 2

Management of Associated Symptoms

Nausea and Vomiting

• Add antiemetics (metoclopramide 10 mg IV or prochlorperazine 10 mg IV) for nausea, which also provide synergistic analgesia 2, 4
• Select non-oral routes of administration when significant nausea or vomiting is present 1, 2
• Prochlorperazine can be given orally at 25 mg (maximum 3 doses per 24 hours) combined with diphenhydramine to prevent extrapyramidal side effects 4

Critical Consideration: Cannabis Discontinuation

Addressing the Root Cause

• Discontinue cannabis use immediately, as continued use perpetuates the headache cycle similar to other medication-overuse headaches 2
• Cannabis-induced headache likely represents a form of medication-overuse headache, given that frequent acute medication use (more than twice weekly) leads to increasing headache frequency 2
• While research shows cannabis may reduce migraine frequency in some patients 5, 6, evidence also demonstrates tolerance develops with continued use, requiring larger doses over time 6

Rebound Headache Risk

• Rebound headache is associated with withdrawal of analgesics or abortive migraine medications 2
• Limit acute therapy to no more than twice per week to guard against medication-overuse headache 2

Treatments to Avoid

Opioids Should Be Last Resort

• Reserve opioids only for cases where other medications cannot be used, sedation is not a concern, and abuse risk has been addressed 1, 2
• Opioids lead to dependency, rebound headaches, and eventual loss of efficacy 2
• If an opioid must be used, butorphanol nasal spray has better evidence than other opioid formulations 2

Severe or Refractory Cases

IV Combination Therapy

• For severe presentations requiring emergency treatment, use IV metoclopramide 10 mg plus IV ketorolac 30 mg as first-line combination therapy 2
• This combination provides rapid pain relief while minimizing side effects and rebound headache risk 2
• Prochlorperazine 10 mg IV is comparable to metoclopramide in efficacy for headache relief 2, 4

Status Migrainosus

• Systemic corticosteroids are the treatment of choice for prolonged, severe headache (status migrainosus) 3

Important Clinical Pitfalls

Common Mistakes to Avoid

• Do not continue cannabis use while treating the headache, as this perpetuates the cycle 2
• Avoid prescribing medications that can themselves cause medication-overuse headache (opioids, butalbital-containing compounds) 2, 3
• Do not restrict antiemetics only to vomiting patients—nausea itself is disabling and warrants treatment 1

Contraindications

• Triptans should be avoided in patients with cardiovascular disease 3
• Ketorolac requires caution in renal impairment, GI bleeding history, or heart disease 2
• Metoclopramide is contraindicated in pheochromocytoma, seizure disorder, GI bleeding, and GI obstruction 2

Preventive Therapy Consideration

• Evaluate for preventive therapy if cannabis-induced headaches occur frequently (two or more attacks per month producing disability lasting 3+ days) 1, 4
• Generally accepted indications include contraindication to or failure of acute treatments, or use of abortive medication more than twice per week 1
• First-line preventive agents include β-blockers (propranolol, timolol), antidepressants (amitriptyline), or anticonvulsants (divalproex sodium) 3