Acute Treatment: Tension Headaches vs Migraine Headaches
Tension-Type Headache (TTH) - Acute Treatment
For acute tension-type headache, use ibuprofen 400 mg or acetaminophen 1000 mg as first-line therapy. 1
Key Treatment Points for TTH:
- Ibuprofen 400 mg demonstrates statistically significant improvement in pain-free response at 2 hours 1
- Acetaminophen 1000 mg is effective for acute TTH, with an NNT of 22 for pain-free at 2 hours 1, 2
- Critical dosing note: Lower doses of acetaminophen (500-650 mg) do NOT show statistically significant improvement and should be avoided 1
- Both medications have similar adverse event profiles to placebo 1, 2
Important Caveats for TTH:
- OnabotulinumtoxinA is NOT recommended for chronic TTH (showed no significant improvement in critical outcomes) 1
- Physical therapy and aerobic exercise can be used as adjunctive management 1
Migraine Headache - Acute Treatment
For acute migraine, start with NSAIDs (ibuprofen, naproxen, diclofenac, aspirin) or acetaminophen at appropriate doses for mild-to-moderate attacks; escalate to triptans or newer CGRP antagonists (gepants) for moderate-to-severe attacks or when first-line agents fail. 1, 3, 4
First-Line Treatment Algorithm for Migraine:
Mild-to-Moderate Migraine:
- NSAIDs (aspirin, ibuprofen, naproxen, diclofenac, celecoxib) at appropriate dosages 1, 3, 4
- Acetaminophen can be used, though less robust evidence than NSAIDs 1, 3
- Combination therapy (NSAID + acetaminophen) may enhance efficacy 3
- Ibuprofen 400 mg provides pain relief in approximately 50% of patients at 2 hours (NNT 3.2 for headache relief) 5
Moderate-to-Severe Migraine or First-Line Failure:
- Triptans are the established standard (sumatriptan most commonly used) 4, 6
- Combination of triptan + NSAID provides superior efficacy compared to single agents 4
- If one triptan fails, trying another triptan may provide relief 4
Second-Line Treatment for Migraine:
When patients don't respond to or cannot tolerate first-line options:
- CGRP antagonists (gepants): rimegepant, ubrogepant, zavegepant 1, 3, 4
- Dihydroergotamine (mesylate) 1
Third-Line Treatment for Migraine:
For refractory migraine not responding to all other options:
- Lasmiditan (ditan - selective 5-HT1F agonist) 1, 3, 4
- Efficacy comparable to triptans but potential for driving impairment 4
Critical Differences Between TTH and Migraine Treatment
Dosing Distinctions:
- TTH: Simple analgesics at standard doses (ibuprofen 400 mg, acetaminophen 1000 mg) are sufficient 1
- Migraine: Requires higher-potency agents (triptans, gepants) for moderate-to-severe attacks, with escalation strategy 1, 4
Medication Classes:
- TTH: Limited to NSAIDs and acetaminophen 1
- Migraine: Multiple classes available including triptans, gepants, ditans, dihydroergotamine, and combination therapies 1, 3, 4
Universal Cautions and Pitfalls
Absolute Contraindications:
- NEVER use opioids or butalbital for acute migraine due to dependency risk and medication overuse headache 3, 7
- Avoid triptans in patients with cardiovascular disease 3, 7
Medication Overuse Headache Prevention:
- NSAIDs/acetaminophen: Limit to <15 days/month 3
- Triptans: Limit to <10 days/month 3, 4
- Medication overuse is a common pitfall that worsens headache frequency and transforms episodic into chronic headache 3, 7
Timing of Treatment:
- Start treatment as early as possible during the migraine attack to improve efficacy 4
- Acute treatments should be limited to no more than twice weekly to prevent medication overuse 4
Special Populations:
- Pregnancy: Acetaminophen is the safest first-line option; avoid NSAIDs and triptans 3, 7
- Nausea/vomiting: Consider non-oral routes of administration or add antiemetics 4, 7