What are the recommended treatments for headaches?

Treatment of Headaches

For acute migraine, start with ibuprofen 400-800 mg or naproxen 500-825 mg as first-line therapy for mild-to-moderate attacks, escalating to a triptan (sumatriptan 50-100 mg) combined with an NSAID for moderate-to-severe attacks or when NSAIDs alone fail. 1, 2

Migraine Treatment Algorithm

First-Line Acute Treatment (Mild-to-Moderate Migraine)

• NSAIDs are the initial choice: Ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 650-1000 mg taken at headache onset 1, 2, 3
• Acetaminophen 1000 mg is an alternative when NSAIDs are contraindicated, though less effective (NNT 12 for 2-hour pain-free response versus NNT 7.2 for ibuprofen 400 mg) 1, 4, 5
• Combination therapy with aspirin + acetaminophen + caffeine provides synergistic benefit for patients responding poorly to single-agent NSAIDs 1, 2

Second-Line Acute Treatment (Moderate-to-Severe Migraine)

• Triptans are the cornerstone: Sumatriptan 50-100 mg, rizatriptan, naratriptan, or zolmitriptan taken early in the attack 1, 2, 6
• Combination therapy is superior to monotherapy: Triptan + NSAID (e.g., sumatriptan 100 mg + naproxen 500 mg) provides the highest efficacy, with 130 additional patients per 1000 achieving sustained pain relief at 48 hours compared to either agent alone 2
• Subcutaneous sumatriptan 6 mg delivers the fastest and most effective relief (59% pain-free at 2 hours, onset within 15 minutes) for severe attacks or when vomiting prevents oral intake 1, 2, 6

Third-Line Acute Treatment (Refractory Cases)

• CGRP antagonists (gepants): Rimegepant or ubrogepant when triptans fail or are contraindicated 1, 2, 7
• Dihydroergotamine (DHE): Intranasal or IV formulation for triptan-refractory migraine 1, 2, 7
• Greater occipital nerve block: For short-term treatment when pharmacotherapy fails 1

Adjunctive Therapy for Nausea/Vomiting

• Metoclopramide 10 mg IV or oral provides direct analgesic effects beyond antiemetic properties through central dopamine receptor antagonism 2, 7
• Prochlorperazine 10 mg IV is equally effective to metoclopramide with a more favorable side effect profile (21% adverse events versus 50% with chlorpromazine) 2
• Add antiemetics 20-30 minutes before analgesics to enhance absorption and provide synergistic pain relief 2

Emergency Department "Migraine Cocktail"

• Optimal IV combination: Metoclopramide 10 mg IV + ketorolac 30 mg IV provides rapid relief with minimal rebound risk 2, 7
• Alternative: Prochlorperazine 10 mg IV + ketorolac 30 mg IV for patients intolerant to metoclopramide 2
• Avoid IV ketamine for acute migraine treatment 1

Tension-Type Headache Treatment

Acute Treatment

• Ibuprofen 400 mg or acetaminophen 1000 mg as first-line therapy 1, 8

Preventive Treatment (Chronic Tension-Type Headache)

• Amitriptyline 30-150 mg daily is the recommended preventive agent 1, 8
• Avoid botulinum toxin injections for chronic tension-type headache prevention 1

Cluster Headache Treatment

Acute Treatment

• Subcutaneous sumatriptan 6 mg or intranasal zolmitriptan 10 mg are first-line abortive agents 1, 8
• Normobaric oxygen therapy (high-flow oxygen via non-rebreather mask) provides effective relief 1
• Noninvasive vagus nerve stimulation for episodic cluster headache 1

Preventive Treatment

• Galcanezumab for episodic cluster headache prevention 1, 8
• Avoid galcanezumab for chronic cluster headache (insufficient efficacy) 1
• Insufficient evidence for verapamil despite widespread clinical use 1

Critical Medication Frequency Limitation

Restrict all acute headache medications to no more than 2 days per week (or 8-10 days per month) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 1, 2, 7

• When patients require acute treatment more than twice weekly, immediately initiate preventive therapy rather than increasing acute medication frequency 2
• Medication-overuse headache develops with ≥15 days/month of NSAID use or ≥10 days/month of triptan use 7

Treatments to Avoid

• Opioids (hydromorphone, meperidine, oxycodone) should be avoided due to dependency risk, rebound headaches, and loss of efficacy; reserve only for cases where all other options are contraindicated and abuse risk has been addressed 1, 2, 7
• Butalbital-containing compounds carry similar risks of dependency and medication-overuse headache 2, 7
• IV ketamine is not recommended for acute migraine treatment 1
• Implantable sphenopalatine ganglion stimulators are not recommended for cluster headache 1
• Patent foramen ovale closure is not recommended for migraine treatment or prevention 1

Nonpharmacologic Adjuncts

• Physical therapy for tension-type, migraine, or cervicogenic headache management 1
• Aerobic exercise or progressive strength training for prevention of tension-type and migraine headaches 1
• Insufficient evidence currently exists to recommend for or against acupuncture, biofeedback, cognitive behavioral therapy, or mindfulness-based therapies, though these may be considered as adjuncts 1

Common Pitfalls to Avoid

• Do not delay triptan administration: Triptans work best when taken early during the attack while pain is still mild, not after waiting to see if NSAIDs work 2
• Do not assume all triptans are equivalent: Failure of one triptan does not predict failure of others; trial a different triptan before abandoning the class 2
• Do not use antiemetics only for vomiting patients: Nausea itself is disabling and warrants treatment even without vomiting 2
• Do not continue ineffective acute therapy: If a patient requires acute treatment more than twice weekly, transition to preventive therapy immediately rather than allowing escalating acute medication use 2