Treatment of Cephalgia (Headaches)
For most adults with acute episodic migraine headaches, start with NSAIDs (ibuprofen, naproxen sodium, aspirin, or diclofenac potassium) as first-line therapy, and add a triptan if NSAIDs alone provide inadequate relief. 1
First-Line Treatment: NSAIDs
Begin treatment with NSAIDs immediately at headache onset for maximum efficacy. 2 Options include:
The combination of acetaminophen + aspirin + caffeine is effective for migraine treatment. 1, 2
Acetaminophen alone is NOT recommended as it is ineffective for migraine. 1
Second-Line Treatment: Add Triptans
When NSAIDs fail to provide adequate relief, add a triptan to the NSAID regimen rather than switching entirely. 1
The American College of Physicians strongly recommends adding a triptan to an NSAID for moderate to severe acute episodic migraine in nonpregnant adults who do not respond adequately to NSAIDs alone. 1
If acetaminophen was used initially (though not recommended as monotherapy), add a triptan to acetaminophen for inadequate response. 1
Effective triptan options include:
Triptans are most effective when taken early during an attack while headache is still mild. 2
If one triptan fails, try a different triptan as individual response varies. 2
Special Considerations for Triptans
For patients with severe nausea or vomiting, use non-oral triptan formulations (subcutaneous, intranasal) and add an antiemetic such as metoclopramide or prochlorperazine. 2
Before prescribing triptans, perform cardiovascular evaluation in triptan-naive patients with multiple cardiovascular risk factors (increased age, diabetes, hypertension, smoking, obesity, strong family history of CAD). 4
Triptans are contraindicated in patients with:
Third-Line Treatment: Newer Agents
- For patients who fail all available triptans or have contraindications, consider CGRP antagonists-gepants (rimegepant, ubrogepant, zavegepant), ditans (lasmiditan), or dihydroergotamine. 1, 2
Critical Medications to AVOID
Avoid opioids and butalbital-containing medications for acute migraine treatment due to questionable efficacy, adverse effects, risk of dependency, and medication overuse headache. 1, 2, 5
Medication Overuse Headache Prevention
Limit acute treatment use to prevent medication overuse headache:
If medication overuse is suspected, consider preventive therapy and detoxification from overused medications. 4
When to Consider Preventive Therapy
Initiate preventive treatment when patients experience: 1, 2
- ≥2 migraine attacks per month producing disability for ≥3 days per month 1
- Use of rescue medication >2 times per week 1
- Failure of or contraindications to acute treatments 1
- Uncommon migraine conditions (prolonged aura, migrainous infarction, hemiplegic migraine) 1
First-Line Preventive Agents
- Propranolol 80-240 mg/day 1, 2
- Timolol 20-30 mg/day 1, 2
- Amitriptyline 30-150 mg/day 1, 2
- Divalproex sodium 500-1,500 mg/day or sodium valproate 800-1,500 mg/day 1, 2
Essential Lifestyle Modifications
Counsel all patients on lifestyle modifications that reduce migraine frequency and severity: 2, 5
- Maintain adequate hydration 2, 5
- Eat regular meals 2
- Ensure sufficient and consistent sleep 2, 5
- Engage in regular physical activity 2, 5
- Practice stress management techniques 2, 5
- Achieve weight loss if overweight or obese 2, 5
Treatment Algorithm Summary
- Start NSAIDs immediately at headache onset 2
- If inadequate response, add triptan to NSAID (strong recommendation for moderate-to-severe migraine) 1
- If combination therapy fails or contraindications exist, consider CGRP antagonists-gepants, ditans, or dihydroergotamine 1, 2
- Monitor for medication overuse and consider preventive therapy if using acute treatments too frequently 1, 2, 4
- Never use opioids or butalbital as routine treatment 1, 2, 5