What is the initial management for an acute headache?

Initial Management of Acute Headache

For acute headache presenting to medical attention, immediately assess for red flags requiring urgent evaluation (thunderclap onset, fever with neck stiffness, focal neurological deficits, new onset after age 50), then treat primary headaches with NSAIDs as first-line therapy for mild-to-moderate pain or triptans for moderate-to-severe pain. 1, 2, 3

Immediate Red Flag Assessment

Before initiating treatment, rapidly screen for secondary causes requiring urgent intervention: 1

• Thunderclap headache (sudden, severe onset) suggests subarachnoid hemorrhage 1
• Fever with neck stiffness indicates possible meningitis 1
• Focal neurological symptoms (weakness, vision changes, altered consciousness) suggests stroke, mass lesion, or other structural pathology 1
• Progressive headache worsening over days to weeks raises concern for intracranial space-occupying lesion 1
• New onset after age 50 warrants consideration of temporal arteritis and other secondary causes 1
• Head trauma history suggests subdural hematoma 1

If any red flags are present, defer treatment and proceed immediately to neuroimaging and appropriate diagnostic workup. 1

First-Line Pharmacologic Treatment Algorithm

For Mild-to-Moderate Headache:

Start with NSAIDs as first-line therapy: 1, 2, 3

• Ibuprofen 400-800 mg orally at onset 1, 2, 4
• Naproxen sodium 500-825 mg orally at onset 2, 3
• Aspirin 900-1000 mg orally at onset 1, 3
• Diclofenac potassium 50-100 mg orally at onset 1, 3

Advise early administration when pain is still mild, as effectiveness depends critically on timing. 1, 2 Maximum ibuprofen dose is 3200 mg daily, but do not exceed twice-weekly use of acute medications to prevent medication-overuse headache. 1, 4

For Moderate-to-Severe Headache:

Escalate to triptans as first-line therapy: 1, 2, 3

• Sumatriptan 50-100 mg orally (most evidence-based option) 2, 3
• Rizatriptan 10 mg orally 1, 2
• Naratriptan 2.5 mg orally 2
• Zolmitriptan 2.5-5 mg orally 2

For patients with significant nausea or vomiting, use non-oral routes: 2, 3

• Subcutaneous sumatriptan 6 mg provides fastest relief (59% pain-free at 2 hours) 2
• Intranasal sumatriptan 5-20 mg or intranasal zolmitriptan 2, 3

Critical contraindication: Avoid triptans in patients with cardiovascular disease, uncontrolled hypertension, or previous myocardial infarction due to vasoconstrictive properties. 2, 5

Combination and Adjunctive Therapy

For enhanced efficacy, combine triptans with fast-acting NSAIDs to prevent symptom recurrence (which occurs in 40% of patients within 48 hours). 1, 3 This combination provides superior efficacy compared to either agent alone. 3

Add antiemetics for nausea/vomiting: 1, 2

• Metoclopramide 10 mg orally or IV (provides synergistic analgesia beyond anti-nausea effect) 1, 2
• Prochlorperazine 10 mg IV or 25 mg orally 2

Administer antiemetics 20-30 minutes before oral analgesics to overcome gastric stasis and improve absorption. 2

Third-Line Options for Refractory Cases

If NSAIDs and triptans fail after adequate trials: 1, 3

• Gepants (rimegepant, ubrogepant, zavegepant) - CGRP antagonists safe in cardiovascular disease 1, 3, 5
• Lasmiditan (ditan) - comparable efficacy to triptans but causes driving impairment for 8 hours 1, 3
• Intranasal dihydroergotamine (DHE) - effective but avoid with cardiovascular disease 2

Critical Pitfalls to Avoid

Medication-overuse headache prevention: Limit all acute medications to no more than twice weekly (not twice per attack, but twice per week total). 1, 2, 3 Frequent use (>2 days/week) creates a vicious cycle of increasing headache frequency leading to daily headaches. 1, 2

Avoid these medications: 1

• Opioids (hydromorphone, oxycodone) - questionable efficacy, high dependency risk, cause rebound headaches 1, 2
• Barbiturates - significant adverse effects and dependency risk 1
• Oral ergot alkaloids - poorly effective and potentially toxic 1

Reserve opioids only for cases where all other options are contraindicated, sedation is acceptable, and abuse risk has been addressed. 2

When to Initiate Preventive Therapy

If headaches continue impairing quality of life despite optimized acute therapy, or if acute medications are needed more than 2 days per week, transition to daily preventive therapy rather than increasing acute medication frequency. 1, 2 Preventive options include antihypertensives, antiepileptics, CGRP monoclonal antibodies, or onabotulinumtoxinA, with efficacy requiring 2-3 months for oral agents. 1