What is the treatment for a 21-year-old patient with headaches for two days?

Treatment for a 21-Year-Old with Two Days of Headache

For a 21-year-old with headache lasting two days, start with ibuprofen 400-600 mg or naproxen sodium 500-825 mg as first-line treatment, taken as early as possible when pain is still mild. 1, 2

Initial Assessment Priorities

Before initiating treatment, briefly assess for red flags requiring urgent evaluation:

• Abrupt onset or "thunderclap" pattern 3, 4
• Neurologic symptoms or abnormal signs (weakness, vision changes, confusion) 3, 4
• Fever with neck stiffness 2
• Recent head or neck trauma 3, 4
• Headache provoked by Valsalva maneuver, cough, or exertion 3, 4

If any red flags are present, neuroimaging (MRI preferred, CT if acute trauma suspected) and further workup are indicated before treatment. 3, 4

First-Line Pharmacologic Treatment

For Mild to Moderate Headache

NSAIDs are the recommended first-line therapy:

• Ibuprofen 400-600 mg orally 1, 2, 5
• Naproxen sodium 500-825 mg orally 1, 2, 5
• Aspirin 1000 mg orally 1, 5

Combination therapy with acetaminophen plus aspirin plus caffeine can be used if NSAIDs alone are insufficient. 1, 2

For Moderate to Severe Headache

If NSAIDs provide inadequate relief, escalate to combination therapy:

• Triptan (sumatriptan 50-100 mg, rizatriptan 10 mg, or zolmitriptan 2.5-5 mg) PLUS an NSAID 1, 2, 5

This combination provides superior efficacy compared to either agent alone. 1, 5

Timing of Administration

Begin treatment as early as possible during the attack, ideally when pain is still mild, as this significantly improves efficacy. 1, 2, 5

Adjunctive Treatment for Nausea

If nausea is present (even without vomiting):

• Add metoclopramide 10 mg orally 20-30 minutes before the analgesic 2
• Metoclopramide provides synergistic analgesia beyond just treating nausea 2

Critical Medication Safety Warnings

Avoid Opioids and Butalbital

Do not use opioids or butalbital-containing compounds for acute episodic headache, as they lead to dependency, rebound headaches, and loss of efficacy. 1, 6, 2

Prevent Medication Overuse Headache

Limit acute treatment to no more than 2 days per week (or 10 days per month for triptans, 15 days per month for NSAIDs) to prevent medication overuse headache. 1, 2, 5

If the patient is already using acute medications more frequently than twice weekly, medication overuse headache should be suspected. 2, 7

NSAID Precautions

Contraindications for NSAIDs include: 8

• Active GI bleeding or history of peptic ulcer disease
• Severe renal impairment (creatinine clearance <30 mL/min)
• Aspirin/NSAID-induced asthma
• Pregnancy after 30 weeks gestation (avoid NSAIDs completely)
• Between 20-30 weeks pregnancy (use only if necessary with monitoring)

When to Consider Preventive Therapy

If headaches occur more than 2 days per week or significantly impair quality of life, initiate preventive therapy rather than increasing frequency of acute treatment. 1, 2, 5

First-line preventive options for young adults include:

• Propranolol 80-160 mg daily 1
• Topiramate 50-100 mg daily 1
• Amitriptyline 10-100 mg at night 1

Follow-Up and Monitoring

Reassess treatment response within 2-3 months to evaluate effectiveness, adverse events, and adherence. 1

If initial treatment fails after 2-3 headache episodes, consider switching to a different triptan or escalating to newer agents (gepants: rimegepant, ubrogepant, zavegepant). 1, 2, 5

Common Pitfalls to Avoid

• Do not allow patients to increase frequency of acute medication use in response to treatment failure, as this creates medication overuse headache. 2
• Do not assume treatment failure after a single use—triptans may work for subsequent attacks even if the first attempt fails. 2
• Do not delay preventive therapy in patients requiring acute treatment more than twice weekly. 2, 5