Outpatient Treatment for Acute Headache Without Red Flags
For moderate to severe acute headache without red flags, add a triptan to an NSAID (such as naproxen 500 mg with sumatriptan 50-100 mg) if the patient has already tried an NSAID alone without adequate relief. 1
Initial Assessment and Treatment Strategy
First-Line Approach for Mild to Moderate Headache
- Start with an NSAID monotherapy: ibuprofen 400-600 mg, naproxen 500 mg, diclofenac potassium, or aspirin 500-1000 mg 1, 2
- If NSAIDs are contraindicated or not tolerated, use acetaminophen 1000 mg 1
- For mild episodic headache, consider the combination of an NSAID plus acetaminophen 1
Escalation for Moderate to Severe Headache
The American College of Physicians strongly recommends combination therapy as the most effective approach: 1
Triptan + NSAID combination (e.g., sumatriptan 50-100 mg + naproxen 500 mg) provides the greatest net benefit with moderate-certainty evidence 1
Triptan + acetaminophen combination (e.g., rizatriptan + acetaminophen 1000 mg) is recommended when NSAIDs are contraindicated, though with lower-certainty evidence 1
Specific Triptan Options
Available triptans include almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, or zolmitriptan 1
- If one triptan fails, try another within the same class as patients may respond differently 1, 2
- Choose based on route of administration preference and cost 1
- Sumatriptan tablets achieve headache response (reduction to mild or no pain) in 52-62% of patients at 2 hours versus 17-27% with placebo 3
Timing and Administration
- Begin treatment as soon as possible after headache onset to maximize efficacy 1, 4
- For severe nausea or vomiting, use a non-oral triptan formulation with an antiemetic 1, 2
Second-Line Options for Treatment Failures
If combination therapy of triptan + NSAID or acetaminophen fails or is not tolerated: 1
- Consider CGRP antagonists-gepants (rimegepant, ubrogepant, or zavegepant) 1
- Consider ergot alkaloid dihydroergotamine 1
- Lasmiditan (ditan) may be used if all other treatments fail 1
Critical Contraindications and Warnings
Medications to Avoid
Do not use opioids or butalbital for acute headache treatment due to dependency risk, rebound headaches, and eventual loss of efficacy 1, 2
Triptan Contraindications
Triptans are contraindicated in patients with: 3
- Coronary artery disease or history of myocardial infarction
- Prinzmetal's angina or coronary artery vasospasm
- Wolff-Parkinson-White syndrome or other cardiac accessory conduction pathway disorders
- History of stroke or transient ischemic attack
- Peripheral vascular disease
- Uncontrolled hypertension
- Hemiplegic or basilar migraine
Cardiovascular Risk Assessment
For triptan-naive patients with multiple cardiovascular risk factors (increased age, diabetes, hypertension, smoking, obesity, strong family history of CAD), perform cardiovascular evaluation before prescribing 3
Medication Overuse Headache Prevention
Be aware of medication overuse headache thresholds: 1, 2
- NSAIDs: ≥15 days per month
- Triptans: ≥10 days per month
- Defined as headache occurring ≥15 days per month for at least 3 months in patients with preexisting headache disorder 1
If frequent episodic headaches occur or acute treatment provides inadequate response, consider adding preventive medications 1
Lifestyle Modifications
Counsel patients on non-pharmacologic interventions: 1, 4, 2
- Maintain adequate hydration and regular meals
- Ensure sufficient and consistent sleep (7-9 hours)
- Engage in regular moderate to intense aerobic exercise
- Practice stress management with relaxation techniques or mindfulness
- Pursue weight loss if overweight or obese
- Identify and avoid personal headache triggers through detailed history