What are the recommended treatments for headaches?

Recommended Treatments for Headaches

Acute Migraine Treatment

For moderate to severe migraine, start with combination therapy of a triptan plus an NSAID or acetaminophen, taken as early as possible at headache onset. 1

First-Line Pharmacologic Options

Combination Therapy (Preferred):

• Aspirin 250 mg + acetaminophen 250 mg + caffeine 65 mg is strongly recommended for acute migraine treatment 1
• Triptan + NSAID or acetaminophen combination provides superior efficacy compared to monotherapy 1

Triptans (for moderate to severe attacks):

• Strongly recommended options: eletriptan, frovatriptan, rizatriptan, sumatriptan (oral or subcutaneous), sumatriptan/naproxen combination, or zolmitriptan (oral or intranasal) 1
• Subcutaneous sumatriptan 6 mg provides highest efficacy (59% pain-free at 2 hours) with fastest onset (15 minutes) 2, 3
• Oral sumatriptan 50-100 mg achieves headache response in 50-62% at 2 hours versus 17-27% with placebo 3

NSAIDs and Acetaminophen:

• Acetaminophen 1000 mg, aspirin, ibuprofen 400 mg, or naproxen 500-825 mg are suggested for acute migraine 1
• Acetaminophen 1000 mg achieves 57.8% headache response at 2 hours versus 38.7% with placebo (NNT 5.2) 4, 5
• Naproxen should be taken at onset when pain is mild, can repeat every 2-6 hours (maximum 1.5 g/day) 2

CGRP Antagonists (Gepants):

• Rimegepant or ubrogepant are suggested as alternatives when triptans fail or are contraindicated 1
• These have lower likelihood of pain freedom compared to triptan/NSAID combinations but may be appropriate second-line options 1

Severe Migraine with Nausea/Vomiting

For patients with significant nausea or vomiting, use non-oral routes:

• Intranasal sumatriptan 5-20 mg or zolmitriptan 10 mg 2
• Subcutaneous sumatriptan 6 mg 1, 2
• Consider antiemetic co-therapy: metoclopramide 10 mg provides synergistic analgesia beyond treating nausea 2

Intravenous options for severe attacks:

• Metoclopramide 10 mg IV + ketorolac 30 mg IV is the recommended first-line IV combination 2
• Prochlorperazine 10 mg IV is equally effective to metoclopramide 2

Critical Medication Overuse Warning

Limit acute medication use to no more than 2 days per week to prevent medication overuse headache:

• NSAIDs: ≥15 days/month triggers medication overuse headache 1
• Triptans: ≥10 days/month triggers medication overuse headache 1
• If using acute medications more frequently, initiate preventive therapy immediately 1, 2

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Tension-Type Headache Treatment

For acute tension-type headache, use ibuprofen 400 mg or acetaminophen 1000 mg. 1

For prevention of chronic tension-type headache:

• Amitriptyline is suggested as the preventive agent 1
• Botulinum toxin injection is NOT recommended for tension-type headache prevention 1

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Cluster Headache Treatment

Acute Treatment:

• Subcutaneous sumatriptan 6 mg or intranasal zolmitriptan 10 mg are suggested for acute cluster attacks 1
• Normobaric oxygen therapy is suggested for acute treatment 1
• Noninvasive vagus nerve stimulation is suggested for episodic cluster headache 1

Preventive Treatment:

• Galcanezumab is suggested for prevention of episodic cluster headache 1
• Galcanezumab is NOT recommended for chronic cluster headache 1

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Migraine Prevention

Initiate preventive therapy when:

• Headaches occur more than 2 days per week 1
• Acute treatment provides inadequate response after adequate trials 1
• Patient cannot tolerate acute medications or has contraindications 1

First-Line Preventive Options (based on cost-effectiveness):

• Topiramate for episodic and chronic migraine 1
• Propranolol for migraine prevention 1
• Valproate for episodic migraine 1
• Amitriptyline (though primarily studied for tension-type headache) 1

Additional Preventive Options:

• Memantine for episodic migraine 1
• Atogepant for episodic migraine 1
• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) 1
• OnabotulinumtoxinA injection for chronic migraine only (NOT episodic migraine) 1

Second-Line Options (if first-line fails or contraindicated):

• ACE inhibitor (lisinopril) 1
• ARBs (candesartan or telmisartan) 1
• SSRI (fluoxetine) 1

Important: Preventive therapy requires 2-3 months for oral agents to show efficacy; switch if inadequate response after this trial period 1

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Medications to AVOID

Do NOT use for migraine:

• Opioids (including hydromorphone) - reserved only when all other options exhausted and abuse risk addressed 1, 2
• Butalbital-containing compounds 1
• Intravenous ketamine for acute migraine 1
• Gabapentin for episodic migraine prevention 1

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Special Populations

Pregnancy and Breastfeeding:

• Discuss adverse effects of all pharmacologic treatments during pregnancy and lactation before initiating therapy 1

Dengue Patients:

• Avoid NSAIDs due to bleeding risk with thrombocytopenia 6
• Use acetaminophen as first-line therapy 6
• Consider metoclopramide 10 mg for severe headaches unresponsive to acetaminophen 6
• Monitor platelet counts and liver function regularly 6

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Non-Pharmacologic Interventions

Suggested interventions:

• Physical therapy for tension-type, migraine, or cervicogenic headache 1
• Aerobic exercise or progressive strength training for prevention 1
• Greater occipital nerve block for acute migraine treatment 1

Lifestyle modifications:

• Maintain hydration, regular meals, consistent sleep schedule 1
• Engage in regular moderate-to-intense aerobic exercise 1
• Manage stress with relaxation techniques or mindfulness 1
• Identify and avoid modifiable migraine triggers 1