What medication can be given for a headache?

Treatment for Headache

For most headaches, start with ibuprofen 400 mg or naproxen 500-550 mg as first-line therapy; if this fails after 2-3 attacks or for moderate-to-severe migraine, escalate to a triptan (sumatriptan 50-100 mg, rizatriptan, or zolmitriptan) combined with an NSAID. 1, 2

First-Line Treatment: NSAIDs and Acetaminophen

• Ibuprofen 400 mg is the most effective over-the-counter option, providing 2-hour headache relief in 57% of patients versus 25% with placebo (NNT 3.2) 3, 4
• Naproxen 500-550 mg is equally effective and recommended as first-line therapy 1, 2
• Aspirin (acetylsalicylic acid) and diclofenac potassium also have strong evidence for efficacy 1
• Acetaminophen 1000 mg is significantly less effective (NNT 12 for 2-hour pain-free response) and should only be used in patients who cannot tolerate NSAIDs 1, 5
• The combination of aspirin-acetaminophen-caffeine is strongly recommended and more effective than individual components 1

Second-Line Treatment: Triptans

• If NSAIDs fail after adequate trial (2-3 attacks), escalate to triptans 1, 2
• Recommended triptans include: eletriptan, frovatriptan, rizatriptan, sumatriptan (oral 50-100 mg or subcutaneous 6 mg), or zolmitriptan (oral or intranasal) 1, 2
• Triptans are most effective when taken early when headache is still mild 1
• Triptans eliminate pain in 20-30% of patients at 2 hours but cause transient flushing, tightness, or tingling in 25% 6
• Critical contraindications: Do not use triptans in patients with coronary artery disease, previous MI, Prinzmetal angina, uncontrolled hypertension, or basilar/hemiplegic migraine 2, 7

Optimal Combination Therapy for Moderate-to-Severe Migraine

• The standard "headache cocktail" is sumatriptan 50-100 mg + naproxen 500-550 mg + metoclopramide 10 mg (oral or IV) 2
• This combination provides synergistic analgesia and treats associated nausea 2
• For mild-to-moderate migraine, start with naproxen alone and escalate to combination therapy if inadequate response after 2-3 attacks 2
• For moderate-to-severe migraine, use the full triple combination immediately 2

Treatment for Tension-Type Headache

• Ibuprofen 400 mg or acetaminophen 1000 mg are recommended 1
• Ibuprofen is highly effective with significant pain improvement at 2 hours 8
• For chronic tension-type headache prevention, amitriptyline 30-150 mg/day is recommended 1, 8

Alternative Routes and Emergency Settings

• For patients with significant nausea/vomiting, use non-oral routes: subcutaneous sumatriptan 6 mg (fastest onset), intranasal zolmitriptan, or rectal formulations 7
• IV cocktail for emergency department: ketorolac 30-60 mg IV + metoclopramide 10 mg IV or prochlorperazine 10 mg IV 2, 7
• Subcutaneous sumatriptan has very rapid onset, ideal for emergency settings 7
• IV metoclopramide may be used as monotherapy for acute attacks, particularly with nausea/vomiting 7

Third-Line Options (When Triptans Fail or Are Contraindicated)

• Gepants (rimegepant or ubrogepant) eliminate headache in 20% of patients at 2 hours with adverse effects of nausea and dry mouth in 1-4% 1, 6
• Lasmiditan (5-HT1F agonist) has comparable efficacy to triptans but causes temporary driving impairment; safe in patients with cardiovascular risk factors 1, 6

Critical Frequency Limits to Prevent Medication-Overuse Headache

• Limit acute treatment to no more than 2 days per week 2, 7
• Using acute medications more frequently leads to medication-overuse headache (rebound headache) 2, 7
• Headache recurrence occurs in approximately 40% of patients within 24 hours; may repeat sumatriptan after 2 hours (oral) or 1 hour (subcutaneous), but this increases overuse risk 1, 2

Medications to Avoid

• Do not use opioids or butalbital-containing compounds due to dependency risk and medication-overuse headache 2
• Avoid acetaminophen alone for migraine as it is ineffective 2
• Avoid oral ergot alkaloids due to questionable efficacy 7

Timing Considerations

• Take medication early in the attack when pain is still mild for maximum efficacy 1
• Do not take triptans during the aura phase—wait until headache begins 1
• Soluble formulations of ibuprofen provide more rapid 1-hour relief compared to standard tablets 3

Drug Interactions

• Ibuprofen can interfere with aspirin's antiplatelet effects if taken within 2 hours before aspirin; administer ibuprofen at least 2 hours after aspirin or 8 hours before 9
• Ergotamines are contraindicated with concurrent triptan use, beta blockers, antihypertensives, SSRIs, and macrolides 7