What are the different types of headaches and their respective treatments?

Types of Headaches and Their Management

Primary Headache Disorders

The three main primary headache types are migraine, tension-type headache (TTH), and cluster headache, each with distinct clinical features that guide diagnosis and treatment. 1

Migraine

Clinical Features:

• Unilateral location with throbbing character that worsens with routine physical activity 1
• Moderate to severe intensity 1
• Accompanied by nausea/vomiting and/or photophobia and phonophobia 1
• May include visual aura (scotomas) or other prodromal symptoms including food cravings, heightened sensory perceptions, and mood changes 1
• Attacks typically last hours to days if untreated 1

Acute Treatment Algorithm:

For mild to moderate attacks:

• Start with NSAIDs (ibuprofen 400mg, aspirin, naproxen, or diclofenac) or acetaminophen 1000mg combined with caffeine 1, 2
• Acetaminophen alone has limited efficacy and should only be used if NSAIDs are not tolerated 2

For moderate to severe attacks or inadequate response to NSAIDs:

• Advance to triptans (sumatriptan, rizatriptan, zolmitriptan, naratriptan) taken early while headache is still mild 1, 2
• Combining a triptan with an NSAID or acetaminophen improves efficacy over either alone 2
• Subcutaneous sumatriptan 6mg provides pain relief in 70% of patients at 1 hour and 81-82% at 2 hours 3
• If one triptan fails, others may still provide relief 2

For triptan failures or contraindications:

• Use CGRP antagonists (rimegepant, ubrogepant, zavegepant), dihydroergotamine (DHE), or lasmiditan 1, 2
• Rimegepant and ubrogepant eliminate headache in 20% of patients at 2 hours with nausea and dry mouth in 1-4% 4

For patients with nausea/vomiting:

• Use non-oral routes (subcutaneous, intranasal) and add antiemetics like metoclopramide or prochlorperazine 2
• Metoclopramide IV may serve as monotherapy for acute attacks 1

Critical Medication Overuse Prevention:

• Limit acute medication use to ≤10 days/month for triptans and ≤15 days/month for NSAIDs to prevent medication overuse headache 2, 3
• Avoid opioids and butalbital-containing compounds—they are ineffective and promote medication overuse headache 1, 2

Preventive Treatment Indications:

• Consider preventive therapy when patients have ≥2 attacks per month producing disability lasting ≥3 days, contraindication to acute treatments, or use acute medication >2 times per week 2
• Options include topiramate (discuss teratogenicity with women of childbearing potential), ACE inhibitors, ARBs, SSRIs, or CGRP monoclonal antibodies 2

Tension-Type Headache (TTH)

Clinical Features:

• Bilateral location with pressing or tightening (non-pulsatile) quality 1
• Mild to moderate intensity 1
• Not aggravated by routine physical activity 1
• Lacks the accompanying symptoms of migraine (no nausea/vomiting, may have photophobia OR phonophobia but not both) 1

Treatment:

• For acute episodes: ibuprofen 400mg or acetaminophen 1000mg 1
• For chronic TTH prevention: amitriptyline 1
• Avoid botulinum toxin injection—it is not effective for chronic TTH 1

Cluster Headache

Clinical Features:

• Strictly unilateral, severe to very severe intensity headache lasting 15-180 minutes 1
• Frequency of 1-8 attacks per day during cluster periods 1
• Accompanied by ipsilateral cranial autonomic symptoms: lacrimation, conjunctival injection, nasal congestion, rhinorrhea, forehead/facial sweating, ptosis, miosis, or eyelid edema 1
• Affects approximately 0.1% of the general population 1

Acute Treatment:

• Subcutaneous sumatriptan 6mg or intranasal zolmitriptan 10mg 1
• Sumatriptan 6mg provides relief in 49% of patients at 10 minutes and 74-75% at 15 minutes 3
• Normobaric oxygen therapy 1

Preventive Treatment:

• Galcanezumab for episodic cluster headache 1
• Avoid galcanezumab for chronic cluster headache—it is not effective 1
• Verapamil has insufficient evidence but may be considered 1

Secondary Headache Disorders

Secondary headaches result from underlying medical conditions and require immediate evaluation when red flags are present. 1

Red Flag Signs Requiring Urgent Investigation:

Historical red flags:

• Thunderclap headache (sudden onset of worst headache of life) 1, 5
• Atypical aura or new neurological symptoms 1
• Recent head trauma 1
• New-onset headache in patients ≥50 years old 1, 5
• Headache worse with Valsalva maneuver or awakens patient from sleep 1
• Progressive worsening pattern 1

Physical examination red flags:

• Unexplained fever 1
• Focal neurological signs 1, 5
• Papilledema 5
• Neck stiffness 5
• Impaired memory or personality changes 1, 5
• Immunocompromised state 5

Neuroimaging Indications:

• The only role for neuroimaging is to confirm or exclude secondary headache causes suspected based on red flags 1
• For suspected intracranial hemorrhage: head CT without contrast 5
• For most other dangerous causes: MRI is preferred over CT (higher resolution, no radiation exposure) 1, 5
• Neuroimaging is NOT warranted for patients with normal neurologic examination and typical primary headache features 1
• CT sensitivity for subarachnoid hemorrhage: 95% on day 0,74% on day 3,50% at 1 week 6

Medication Overuse Headache (MOH):

• An important secondary headache disorder that commonly develops from overuse of acute migraine medications 1
• Presents as increasing headache frequency, often progressing to daily headaches 1
• Caused by frequent use of ergotamine, opiates, triptans, and analgesics containing butalbital, caffeine, or isometheptene 1
• Insufficient evidence exists for specific preventive agents or withdrawal strategies 1

Diagnostic Tools:

• Use validated screening instruments: ID-Migraine questionnaire (sensitivity 0.81, specificity 0.75) or Migraine Screen Questionnaire (sensitivity 0.93, specificity 0.81) 1
• Maintain headache diaries recording frequency, intensity, associated symptoms, medication use, and menstruation to guide treatment decisions 1, 2