What are the recommended treatments for headaches?

Headache Treatment

First-Line Treatment Based on Headache Type and Severity

For mild to moderate migraine, start with NSAIDs (ibuprofen 400 mg, naproxen 500-825 mg, or aspirin 1000 mg) or acetaminophen 1000 mg, and escalate to triptans combined with NSAIDs or acetaminophen for moderate to severe attacks. 1

Migraine Treatment Algorithm

Mild to Moderate Migraine:

• Ibuprofen 400 mg provides 2-hour headache relief in 57% of patients (NNT 3.2) and 2-hour pain-free response in 26% (NNT 7.2) 2
• Naproxen 500-825 mg at migraine onset, can repeat every 2-6 hours (maximum 1.5 g/day) 3
• Acetaminophen 1000 mg provides 2-hour headache relief in 56% of patients (NNT 5.0), though inferior to other analgesics 4
• Combination therapy with acetaminophen, aspirin, and caffeine enhances efficacy 1

Moderate to Severe Migraine:

• Triptan + NSAID or acetaminophen combination is the recommended first-line approach 1
• Oral triptans (sumatriptan 50-100 mg, rizatriptan, zolmitriptan) provide 2-hour headache response in 50-62% of patients 5
• Subcutaneous sumatriptan 6 mg is most effective, providing complete pain relief in 59% by 2 hours and response in 70-82% within 15 minutes 3, 5
• Intranasal formulations (sumatriptan 5-20 mg or zolmitriptan 10 mg) for patients with severe nausea/vomiting 3

When First-Line Therapy Fails:

• CGRP antagonists (rimegepant, ubrogepant, zavegepant) for patients who don't tolerate or have inadequate response to triptan + NSAID combinations 1
• Lasmiditan only after all other treatments fail 1
• Never use opioids or butalbital for acute episodic migraine 1

Tension-Type Headache Treatment

• Ibuprofen 400 mg or acetaminophen 1000 mg for acute treatment 1
• Amitriptyline 30-150 mg/day for prevention of chronic tension-type headache 1, 3

Cluster Headache Treatment

Acute Treatment:

• Subcutaneous sumatriptan 6 mg or intranasal zolmitriptan 10 mg 1
• Normobaric oxygen therapy 1

Prevention:

• Galcanezumab for episodic cluster headache only (not for chronic) 1

Critical Adjunctive Therapy

Add antiemetics when nausea/vomiting present:

• Metoclopramide 10 mg IV provides direct analgesic effects beyond treating nausea 3
• Prochlorperazine 10 mg IV has comparable efficacy to metoclopramide with fewer adverse events (21% vs 50%) 3
• Administer antiemetics 20-30 minutes before analgesics to enhance absorption 3

Medication Overuse Headache Prevention

Strict frequency limits are essential:

• NSAIDs: ≤15 days per month 1
• Triptans: ≤10 days per month 1
• Overall acute medication use: ≤2 days per week 3
• Medication overuse headache develops after ≥3 months of exceeding these thresholds 1

When to Initiate Preventive Therapy

Start preventive medications if:

• Headaches occur ≥2 times per month causing ≥3 days of disability 3
• Acute medications used >2 days per week 3
• Inadequate response to optimized acute treatment 1

First-line preventive options:

• Propranolol 80-240 mg/day or timolol 20-30 mg/day 3
• Topiramate or divalproex sodium 3
• Amitriptyline 30-150 mg/day for mixed migraine/tension-type headache 3

Essential Clinical Considerations

Timing of treatment:

• Begin treatment as early as possible when headache is still mild to maximize efficacy 1, 3

Route selection:

• Use non-oral routes (subcutaneous, intranasal, rectal) when significant nausea/vomiting present early in attack 3

Cost considerations:

• Prescribe less costly medications first (NSAIDs, acetaminophen, generic triptans) before expensive alternatives 1
• CGRP antagonists cost $4,959-$8,800 annually vs. generic options 1

Special populations:

• Discuss adverse effects during pregnancy/lactation in patients of childbearing potential 1
• Avoid triptans in patients with cardiovascular disease, uncontrolled hypertension, or previous MI 3

Common Pitfalls to Avoid

• Do not allow escalating frequency of acute medication use in response to treatment failure; this creates medication overuse headache 3
• Do not restrict antiemetics only to vomiting patients; nausea itself is disabling and warrants treatment 3
• Do not assume all triptans are equivalent; failure of one triptan doesn't predict failure of others—try different triptans or routes 3
• Do not use IV ketamine for acute migraine treatment 1