What is the difference in treatment between migraines and headaches?

Migraine vs Headache: Treatment Differences

For moderate to severe migraines, add a triptan to an NSAID if the NSAID alone fails to provide adequate relief; for non-migraine headaches (tension-type), NSAIDs or acetaminophen alone are typically sufficient without requiring migraine-specific medications like triptans. 1

Key Diagnostic Distinctions That Drive Treatment

Migraine characteristics that distinguish it from other headaches and necessitate specific treatment:

• Moderate to severe throbbing pain lasting 4-72 hours 1
• Accompanied by nausea, vomiting, photophobia, or phonophobia 1
• Often unilateral and pulsating 1
• May include aura (sensory disturbances) 1

Tension-type headache characteristics requiring different treatment:

• Bilateral, mild to moderate pain with pressing or tightening quality 1
• NOT aggravated by routine physical activity 1
• Lacks the accompanying symptoms of migraine (no nausea, photophobia, phonophobia) 1

Treatment Algorithm Based on Headache Type

For Tension-Type Headaches (Non-Migraine)

• First-line: NSAIDs (ibuprofen, naproxen) or acetaminophen alone 1, 2
• Simple analgesics are typically sufficient 1
• No need for migraine-specific medications 1

For Mild to Moderate Migraines

• First-line: NSAIDs (aspirin, ibuprofen, naproxen sodium) 1, 3
• Alternative first-line: Combination products containing acetaminophen, aspirin, and caffeine 3, 4
• Administer as early as possible during the attack for maximum efficacy 1

For Moderate to Severe Migraines

• First-line: Triptans (sumatriptan, rizatriptan, naratriptan, zolmitriptan) 1, 3
• If NSAID fails: Add a triptan to the NSAID (strong recommendation, moderate-certainty evidence) 1
• If acetaminophen fails: Add a triptan to acetaminophen (conditional recommendation, low-certainty evidence) 1

Migraine-Specific Medications NOT Used for Other Headaches

Triptans are migraine-specific and should not be used for tension-type headaches:

• Oral triptans eliminate pain in 20-30% of patients by 2 hours 4
• Subcutaneous sumatriptan provides highest efficacy (59% complete pain relief by 2 hours) 3
• Contraindicated in patients with cardiovascular disease due to vasoconstrictive properties 4
• Common adverse effects include transient flushing, tightness, or tingling in upper body (25% of patients) 4

Newer migraine-specific agents (not for tension-type headaches):

• Gepants (rimegepant, ubrogepant): CGRP antagonists that eliminate headache in 20% of patients at 2 hours 4
• Ditans (lasmiditan): 5-HT1F agonist, safe in patients with cardiovascular risk factors 4

Critical Treatment Principles for Migraines

Stratified approach based on severity:

• Mild to moderate attacks: Start with NSAIDs 1, 3
• Moderate to severe attacks: Use triptans or add triptan if NSAID fails 1
• Severe attacks with vomiting: Consider non-oral routes (subcutaneous, intranasal) 3, 5

Antiemetics as adjunctive therapy for migraines:

• Metoclopramide (10 mg IV) provides synergistic analgesia beyond treating nausea 3
• Prochlorperazine (10 mg IV) effectively relieves headache pain 3
• These are NOT typically needed for tension-type headaches 1

Common Pitfalls to Avoid

Medication-overuse headache (rebound headache):

• Occurs with frequent use of acute medications (more than twice weekly) 1, 3
• Can develop from overuse of triptans, ergotamines, opiates, or analgesics 1
• Limit acute therapy to no more than 2 days per week 3

Inappropriate medication selection:

• Do NOT use opioids as first-line for either migraine or tension-type headache 3
• Opioids should be reserved only when other medications cannot be used and abuse risk has been addressed 3
• Acetaminophen alone is NOT effective for migraine (though effective in combinations) 1, 6

When to consider preventive therapy:

• More than 2 headaches per week 1
• Frequent use of acute medications 3
• Significant disability despite acute treatment 6

Red Flags Requiring Urgent Evaluation

These suggest secondary headache requiring different management:

• Thunderclap headache (abrupt onset of severe headache) 1
• Headache awakening patient from sleep 1
• Rapidly increasing frequency of headache 1
• Focal neurologic signs or symptoms 1
• New onset in older person (age ≥50 years) 4
• Persistent headache following head trauma 1
• Fever with headache 1