How to treat headaches caused by psychiatric medications (psych meds)?

Treatment of Headaches Caused by Psychiatric Medications

Start with standard headache treatments—acetaminophen or NSAIDs (ibuprofen, naproxen sodium, or aspirin)—if not contraindicated, while simultaneously performing a thorough differential diagnosis to identify other potential causes. 1

Initial Management Approach

First-Line Treatment Options

• NSAIDs are the preferred initial therapy for medication-induced headaches, with the strongest evidence supporting aspirin, ibuprofen, naproxen sodium, and the combination of acetaminophen-aspirin-caffeine. 2
• Acetaminophen alone is ineffective for headache treatment and should not be used as monotherapy. 2
• Standard analgesics can be used immediately upon headache onset for maximum efficacy. 2

Critical Diagnostic Considerations

• Headache is extremely common in the general population and occurs with many medications, making direct attribution to psychiatric medications challenging. 1
• Regular follow-up to monitor headache patterns after starting psychiatric medications is essential. 1
• Maintain a headache diary tracking severity, frequency, duration, disability level, and medication use to identify patterns and prevent medication overuse. 2, 3

Medication Overuse Prevention

Frequency Limitations (Critical to Avoid Rebound Headaches)

• Limit acute headache medication use to no more than 2 days per week to minimize rebound risk. 2, 3
• Simple analgesics (NSAIDs, acetaminophen) should be used fewer than 15 days per month. 3
• Triptans, if prescribed for severe headaches, must be limited to fewer than 10 days per month. 3
• Completely avoid medications containing barbiturates, caffeine, butalbital, or opioids, as these carry the highest risk of causing medication-overuse headache. 3

Rebound Headache Recognition

• Medication-overuse headache presents as increasing headache frequency, often progressing to daily headaches. 2
• This is distinct from rebound headache, which occurs during withdrawal from analgesics or abortive medications. 2
• Ergotamine, opiates, triptans, and analgesics containing butalbital, caffeine, or isometheptene are most likely to cause rebound. 2

When Simple Analgesics Fail

Migraine-Specific Agents

• If NSAIDs are ineffective and the headache has migraine features (throbbing, unilateral, with nausea), consider triptans (naratriptan, rizatriptan, sumatriptan, or zolmitriptan). 2
• Triptans are contraindicated in patients with uncontrolled hypertension, basilar or hemiplegic migraine, or cardiac risk factors. 2
• Intranasal dihydroergotamine (DHE) has good evidence for efficacy and safety. 2

Adjunctive Treatment for Nausea

• If nausea accompanies the headache, intravenous metoclopramide can serve as monotherapy for acute attacks, with the sedating effect being potentially beneficial. 2
• Consider nonoral routes of administration when nausea is prominent. 2

Preventive Therapy Indications

When to Initiate Prevention

Preventive therapy should be started if: 2

• Two or more headache attacks per month producing disability for 3+ days per month
• Acute medications are being used more than twice per week
• Acute treatments have failed or are contraindicated
• The patient is at risk for medication overuse

First-Line Preventive Options

• Amitriptyline 30-150 mg/day has the strongest evidence for headache prevention and is particularly beneficial when psychiatric comorbidity exists (depression, anxiety). 4, 5, 6
• Amitriptyline is superior to beta-blockers for mixed migraine and tension-type headaches. 4
• Beta-blockers (propranolol 80-240 mg/day, timolol 20-30 mg/day) are effective alternatives, particularly for pure migraine without tension features. 4
• SNRIs (venlafaxine, duloxetine) have evidence for efficacy and may be most effective when comorbid depression and migraine coexist. 5, 6

Preventive Therapy Considerations

• Start low and titrate slowly; clinical benefits may take 2-3 months to manifest. 2, 4
• Amitriptyline side effects include weight gain, drowsiness, and anticholinergic symptoms (dry mouth, constipation). 4, 6
• The sedating effect of tricyclic antidepressants can be beneficial for patients with comorbid insomnia. 6
• Nortriptyline lacks evidence for headache prevention despite being in the same class as amitriptyline. 4

Special Considerations for Psychiatric Medication Context

• Psychiatric comorbidities (depression, anxiety) do not negatively influence headache treatment outcomes when contemporary treatments are properly administered. 7
• When possible, select a single agent that treats both the psychiatric condition and prevents headaches (e.g., amitriptyline for depression and headache prevention). 5
• Avoid migraine preventives that may worsen psychiatric comorbidity (e.g., beta-blockers may worsen depression). 5
• Anticonvulsants (divalproex sodium, topiramate) have dual efficacy for mood stabilization and migraine prevention. 5

Rescue Medication Strategy

• For severe headaches unresponsive to other treatments, establish a cooperative arrangement for home rescue medication (opioid or butalbital-containing compound) to avoid emergency department visits. 2
• Rescue medications permit relief without complete pain elimination or return to normal function. 2
• Address appropriate situations for rescue medication use upfront with clear parameters. 2