What are the guidelines for treating headaches?

Headache Treatment Guidelines

Acute Migraine Treatment

For mild to moderate migraine, start with NSAIDs (ibuprofen 400-800mg or naproxen sodium 275-550mg) or acetaminophen 1000mg; for moderate to severe migraine, use triptans combined with NSAIDs as first-line therapy, treating as early as possible after headache onset. 1, 2

First-Line Acute Therapies

• Mild to moderate attacks: Use ibuprofen 400-800mg, naproxen sodium 275-550mg, or acetaminophen 1000mg 2
• Moderate to severe attacks: Triptans (sumatriptan, rizatriptan, zolmitriptan) combined with NSAIDs or acetaminophen are recommended 1, 2
• Aspirin-acetaminophen-caffeine combination shows significant benefit with NNT of 9 for pain freedom at 2 hours 3
• CGRP antagonists (gepants) such as ubrogepant and rimegepant are effective alternatives, particularly for patients with cardiovascular contraindications to triptans 1, 3

Route of Administration Considerations

• For rapid-onset headaches or significant nausea/vomiting: Use non-oral routes including intranasal triptans (zolmitriptan nasal, sumatriptan nasal) or subcutaneous sumatriptan 1, 2
• Add antiemetics (metoclopramide 10mg IV or prochlorperazine 10mg IV) when nausea is prominent 3, 2

Critical Treatment Principles

• Treat early after headache onset for maximum efficacy 2, 4
• If one triptan fails, try another triptan or an NSAID-triptan combination 1
• Avoid opioids and butalbital-containing medications entirely for migraine treatment 1, 2

Medication Overuse Prevention

• Limit acute medication use to ≤2 days per week to prevent medication overuse headache 2
• NSAIDs: Risk threshold is ≥15 days/month 3
• Triptans: Risk threshold is ≥10 days/month 3, 2

Migraine Prevention

For episodic migraine prevention, use angiotensin receptor blockers (candesartan, telmisartan), lisinopril, topiramate, valproate, or CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab); for chronic migraine, use onabotulinumtoxinA or CGRP antibodies. 1, 3

First-Line Preventive Options for Episodic Migraine

• Angiotensin receptor blockers: Candesartan and telmisartan 1, 3
• ACE inhibitor: Lisinopril 1
• Antiepileptics: Topiramate and valproate 1
• CGRP monoclonal antibodies: Eptinezumab, erenumab, fremanezumab, galcanezumab 1, 3
• Oral CGRP antagonist: Atogepant 1

Chronic Migraine Prevention (≥15 headache days/month)

• OnabotulinumtoxinA is specifically recommended for chronic migraine prevention, but NOT for episodic migraine or tension-type headache 1, 3
• CGRP monoclonal antibodies are effective for both episodic and chronic migraine 1, 3

Important Preventive Medication Considerations

• Gabapentin is NOT recommended for episodic migraine prevention 1
• Start preventive medications at low doses and increase slowly until benefits are achieved without adverse effects 3
• Allow adequate trial periods of 2-3 months before determining efficacy 3
• Consider preventive therapy when patients have ≥4 migraine days per month or ≥2 migraine days with significant disability despite appropriate acute therapy 3

Tension-Type Headache Treatment

For acute tension-type headache, use ibuprofen 400mg or acetaminophen 1000mg; for chronic tension-type headache prevention, use amitriptyline 50-100mg. 1, 2

Acute Treatment

• Ibuprofen 400mg is recommended 1, 2
• Acetaminophen 1000mg is recommended 1, 2
• Lower doses of acetaminophen (500-650mg) have NOT shown significant improvement 2
• Combination analgesics containing caffeine may also be effective 3

Preventive Treatment for Chronic Tension-Type Headache

• Amitriptyline 50mg or 100mg is the recommended preventive treatment 1, 3, 2
• Exercise caution with anticholinergic side effects, especially in older patients or those with cardiac conditions 2
• For mixed migraine and tension-type headache, amitriptyline may be more effective than propranolol 3

Non-Pharmacologic Approaches

Physical therapy and aerobic exercise (2-3 times weekly for 30-60 minutes) are recommended for both migraine and tension-type headache prevention. 1, 2

Physical Therapy

• Combination techniques including thermal methods, trigger point massage, and mobilization/manipulation delivered by a physical therapist reduce headache frequency and intensity better than sham interventions or medications 1, 2

Exercise Recommendations

• Aerobic exercise: 2-3 times per week for 30-60 minutes 1, 3, 2
• Upper-body progressive strength training: Supervised, typically 3 times per week for 30 minutes 1
• Benefits extend beyond headache control to include weight reduction and mitigation of future vascular risk 1

Behavioral Medicine Interventions

• Evidence is insufficient to recommend for or against biofeedback, smartphone-based heart rate variability monitoring, cognitive behavioral therapy, mindfulness-based therapies, or progressive muscle relaxation when used alone 1
• Amitriptyline combined with cognitive behavioral therapy has evidence for migraine prevention in children/adolescents 1

Neuromodulation

• Insufficient evidence to recommend for or against any form of neuromodulation for acute or preventive treatment of migraine 1
• If considering neuromodulation, be aware of contraindications for each device type and differences in treatment frequency between acute and preventive settings 1

Pediatric Migraine Considerations

For children and adolescents with acute migraine, use ibuprofen; for adolescents, consider sumatriptan/naproxen oral, zolmitriptan nasal, sumatriptan nasal, rizatriptan ODT, or almotriptan oral. 1

Acute Treatment in Pediatrics

• Ibuprofen is recommended for children and adolescents 1
• Triptans for adolescents: Sumatriptan/naproxen oral, zolmitriptan nasal, sumatriptan nasal, rizatriptan ODT, or almotriptan oral 1
• Avoid aspirin in children and adolescents due to Reye's syndrome risk 2
• Treat early in the attack 1

Preventive Treatment in Pediatrics

• Discuss with patients/families that placebo was as effective as studied medications in many trials 1
• Options with evidence: Amitriptyline combined with cognitive behavioral therapy, topiramate, and propranolol 1
• Counsel about teratogenic effects of topiramate and valproate; advise effective birth control and folate supplementation when relevant 1

Emergency/Urgent Care Treatment

For severe headaches requiring parenteral treatment, use ketorolac 30-60mg IM/IV; for combined pain and nausea, use metoclopramide 10mg IV or prochlorperazine 10mg IV, or combination therapy with IV metoclopramide plus IV ketorolac. 2

• Ketorolac 30-60mg IM/IV for severe headaches 2
• Metoclopramide 10mg IV or prochlorperazine 10mg IV for pain and nausea 2
• Combination therapy with IV metoclopramide plus IV ketorolac for severe migraine attacks 2

Concussion-Related Headache

For concussion-related headaches, use ibuprofen 400-800mg every 6 hours as first-line treatment, or naproxen sodium 275-550mg every 2-6 hours as an alternative. 2

• Ibuprofen 400-800mg every 6 hours is first-line 2
• Naproxen sodium 275-550mg every 2-6 hours provides longer duration 2
• Avoid aspirin in children and adolescents 2

Comparative Efficacy

There is insufficient evidence to recommend one specific medication over another within the same class for either acute or preventive headache treatment; treatment selection should be based on patient-specific factors including comorbidities, contraindications, and prior treatment responses. 1

• No robust head-to-head evidence exists for most comparisons, as phase 3 trials typically compare new therapies versus placebo 1
• The 2023 VA/DoD guidelines found insufficient evidence to recommend any specific medication over another for abortive or preventive treatment after reviewing multiple meta-analyses 1

Essential Lifestyle Modifications

All patients should receive counseling on lifestyle factors including hydration, regular meals, sufficient sleep, physical activity, and stress management. 2

• Hydration, regular meals, sufficient sleep, physical activity, and stress management are emphasized across all headache types 2
• Identify and avoid migraine triggers 1