What is the recommended treatment for pulsatile headaches, specifically migraines?

Treatment for Pulsatile Headache (Migraine)

NSAIDs (aspirin, ibuprofen, naproxen sodium, or diclofenac potassium) are the recommended first-line treatment for most patients with pulsatile migraine headaches, with treatment initiated as early as possible during an attack for maximum efficacy. 1

First-Line Treatment: NSAIDs

• Start with NSAIDs immediately at onset of symptoms - options include aspirin, ibuprofen, naproxen sodium, or diclofenac potassium 2, 1
• Combination therapy of acetaminophen plus aspirin plus caffeine is effective, but acetaminophen alone is not recommended 2, 1
• Early treatment during the attack is critical for maximum efficacy 1

Second-Line Treatment: Triptans

If NSAIDs fail to provide adequate relief, escalate to triptans - these are migraine-specific agents that should be used when first-line therapy is insufficient 2, 1

Triptan Options and Dosing:

• Sumatriptan: 50-100 mg orally (50 mg offers best efficacy-to-tolerability ratio, though many patients require 100 mg) 3, 4
• Rizatriptan, naratriptan, zolmitriptan: all have good evidence for efficacy 2, 1
• Take triptans early while headache is still mild for best results 1
• If one triptan fails, try another - individual response varies 1

Important Triptan Contraindications:

• Absolute contraindications: uncontrolled hypertension, ischemic heart disease, coronary artery disease, Prinzmetal's angina, history of stroke or TIA, basilar or hemiplegic migraine 2, 5, 6
• Perform cardiovascular evaluation in triptan-naïve patients with multiple cardiovascular risk factors (age, diabetes, hypertension, smoking, obesity, strong family history of CAD) before prescribing 5, 6

Adjunctive Treatment for Nausea/Vomiting

• Add antiemetics (metoclopramide or prochlorperazine) for patients with significant nausea or vomiting 1
• Consider non-oral routes of administration (intranasal, subcutaneous) when nausea presents early 2

Third-Line Options for Refractory Cases

• CGRP antagonists (gepants), ditans, or dihydroergotamine for patients who fail all triptans or have contraindications 1
• These are reserved for refractory migraine after exhausting other options 1

Critical Medication Overuse Warning

Limit acute treatment to no more than twice weekly to prevent medication overuse headache 2:

• NSAIDs: avoid using ≥15 days per month 1, 5
• Triptans: avoid using ≥10 days per month 1, 6
• Medication overuse headache presents as daily headaches or marked increase in migraine frequency 5, 6

What to Avoid

Do not use opioids or butalbital-containing medications - these have questionable efficacy, cause dependency, and increase risk of medication overuse headache 1

When to Consider Preventive Therapy

Initiate preventive medications if: 2

• ≥2 migraine attacks per month causing ≥3 days of disability
• Using rescue medication more than twice weekly
• Acute treatments fail or are contraindicated

Preventive options include: propranolol, timolol, amitriptyline, topiramate, or divalproex sodium 2, 1

Essential Lifestyle Modifications

Counsel all patients on: 1

• Adequate hydration and regular meals
• Sufficient and consistent sleep schedule
• Regular physical activity
• Stress management techniques
• Weight loss if overweight or obese