Headache Management Guidelines
Diagnostic Classification
Headaches are categorized into primary disorders (migraine, tension-type, cluster) and secondary disorders (underlying medical conditions), with tension-type headache affecting 38% and migraine affecting 12% of the population. 1
Red Flag Assessment
- Evaluate for urgent features requiring immediate workup: abrupt onset ("thunderclap"), neurologic deficits, age ≥50 years with new-onset headache, cancer or immunosuppression, provocation by physical activity or postural changes 1
- Use focused neurologic examination and head/neck physical examination in all patients 2
- Consider neuroimaging only when red flags are present; routine imaging is not indicated for uncomplicated primary headaches 3
Primary Headache Identification
- Migraine diagnostic criteria: At least 2 of the following: unilateral location, throbbing character, worsening with routine activity, moderate-to-severe intensity; PLUS at least one associated symptom (nausea, photophobia, phonophobia) 4
- Tension-type headache criteria: At least 2 of the following: pressing/tightening (non-pulsatile) character, mild-to-moderate intensity, bilateral location, no aggravation with routine activity 4
- Cluster headache criteria: Five attacks with frequency of 1-8 attacks daily, severe unilateral orbital/supraorbital/temporal pain lasting 15-180 minutes, with ipsilateral autonomic features (lacrimation, nasal congestion, rhinorrhea) 4
Acute Migraine Treatment
First-Line Therapy by Severity
For mild-to-moderate migraine, start with NSAIDs (ibuprofen 400-800mg or naproxen sodium 275-550mg) or acetaminophen 1000mg; for moderate-to-severe migraine, use triptans combined with NSAIDs, treating as early as possible after headache onset. 5
- Aspirin-acetaminophen-caffeine combination shows significant benefit (NNT=9 for pain freedom at 2 hours) 5
- Triptans (sumatriptan, rizatriptan, zolmitriptan) combined with NSAIDs or acetaminophen eliminate pain in 20-30% of patients by 2 hours 1
- For migraine with significant nausea/vomiting, use non-oral routes and add antiemetics 5, 6
Alternative Acute Therapies
- CGRP antagonists (gepants): Ubrogepant and rimegepant are effective alternatives, particularly for patients with cardiovascular contraindications to triptans 5, 4
- Gepants eliminate headache in 20% of patients at 2 hours with adverse effects (nausea, dry mouth) in 1-4% 1
- Lasmiditan (5-HT1F agonist) is safe in patients with cardiovascular risk factors 1
Critical Safety Considerations
Avoid opioids and butalbital-containing analgesics due to dependency risk and medication overuse headache. 4, 6
- Triptans are contraindicated in patients with coronary artery disease, Prinzmetal's angina, uncontrolled hypertension, history of stroke/TIA, or Wolff-Parkinson-White syndrome 7
- Perform cardiovascular evaluation in triptan-naive patients with multiple cardiovascular risk factors before prescribing 7
- Monitor for serotonin syndrome when combining triptans with SSRIs, SNRIs, TCAs, or MAO inhibitors 7
Emergency/Urgent Care Treatment
- Ketorolac 30-60mg IM/IV for severe headaches 5
- Metoclopramide 10mg IV or prochlorperazine 10mg IV for combined pain and nausea 5
- Combination therapy with IV metoclopramide plus IV ketorolac is effective 5
Migraine Prevention
Indications for Preventive Therapy
Consider preventive therapy for patients with ≥2 attacks per month producing disability lasting ≥3 days, contraindication to/failure of acute treatments, or use of abortive medication more than twice weekly. 6
- The American Headache Society recommends preventive therapy when patients have ≥4 migraine days per month or ≥2 migraine days with significant disability despite appropriate acute therapy 8
First-Line Preventive Agents
For episodic migraine prevention, use angiotensin-receptor blockers (candesartan, telmisartan), lisinopril, topiramate, valproate, or CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab). 5, 4
- Propranolol and timolol are traditional first-line options 6
- CGRP monoclonal antibodies are effective for both episodic and chronic migraine 5, 4
- The American Headache Society released a 2024 position statement supporting CGRP-targeting therapies as first-line options for migraine prevention 4
- Atogepant (oral gepant) is effective for episodic migraine prevention 4, 5
Chronic Migraine Prevention
OnabotulinumtoxinA is specifically recommended for chronic migraine prevention (≥15 headache days/month with migraine features on ≥8 days), but NOT for episodic migraine or tension-type headache. 5, 4
- Gabapentin is NOT recommended for prevention of episodic migraine 4
Preventive Therapy Management
- Start preventive medications at low doses and increase slowly until benefits are achieved without adverse effects 8
- Allow adequate trial periods of 2-3 months before determining efficacy 8
- Consider tapering or discontinuing preventive medications after a period of stability 8
- Preventive treatments reduce migraine by 1-3 days per month relative to placebo 1
Tension-Type Headache Management
Acute Treatment
Ibuprofen 400mg or acetaminophen 1000mg are recommended for acute tension-type headache. 5, 4, 6
Preventive Treatment
Amitriptyline 50mg or 100mg is the recommended preventive treatment for chronic tension-type headache, significantly reducing monthly headache days. 5, 4, 6
- OnabotulinumtoxinA is NOT recommended for chronic tension-type headache 4, 6
- Monitor for anticholinergic adverse effects of amitriptyline, especially in older patients and those with cardiac comorbidities 6
Non-Pharmacologic Approaches
Physical Therapy and Exercise
Physical therapy and aerobic exercise (2-3 times weekly for 30-60 minutes) are recommended for both migraine and tension-type headache prevention. 5, 4
- Combination techniques including thermal methods, trigger point massage, and mobilization/manipulation delivered by a physical therapist reduce headache frequency and intensity better than sham interventions or medications 5, 6
- Progressive strength training is also effective for prevention 4, 5
Other Non-Pharmacologic Modalities
- Insufficient evidence exists to recommend for or against biofeedback, cognitive behavioral therapy, mindfulness-based therapies, progressive muscle relaxation, acupuncture, dry needling, or yoga 4
- Noninvasive vagus nerve stimulation is suggested for short-term treatment of episodic cluster headache 4
- Insufficient evidence exists for various neuromodulation devices (supraorbital nerve stimulation, remote electrical neurostimulation, repetitive transcranial magnetic stimulation, transcranial direct current stimulation) for migraine treatment/prevention 4
Medication Overuse Headache
Recognition and Risk Factors
Suspect medication overuse headache in patients with frequent headaches (≥7 days/month) who use acute migraine drugs (ergotamine, triptans, opioids, or combinations) for ≥10 days per month. 7, 8
- Risk factors include frequent use of anxiolytics, analgesics, or sedative-hypnotics, and history of anxiety or depression 8
- Medication overuse can lead to transformation to chronic daily headaches that are intractable and difficult to treat 2
- Include nonprescription analgesics and substances obtained from others in medication history 2
Management Strategy
Detoxification including withdrawal of overused drugs and treatment of withdrawal symptoms (which often includes transient worsening of headache) is necessary. 7
- Patients who overuse opiates, barbiturates, or benzodiazepines require slow tapering and possibly inpatient treatment to prevent acute withdrawal 2
- Patients who overuse other agents can usually withdraw more quickly 2
- Evidence is mixed on the role of medications such as topiramate for patients with medication overuse headache 2
Mixed-Type Headaches
Diagnostic Approach
Properly identify the specific headache types present in mixed presentations, commonly migraine and tension-type headache, distinguishing between episodic (<15 headache days/month) and chronic (≥15 headache days/month) patterns. 8
Treatment Selection
For patients with both migraine and tension-type headache, consider amitriptyline as more effective than propranolol. 8
- For acute treatment, use triptans for migraine attacks and NSAIDs/acetaminophen for tension-type episodes 8
- For prevention, CGRP monoclonal antibodies, angiotensin receptor blockers, or topiramate can address migraine, while amitriptyline addresses both migraine and tension-type headache 8
- Consider combining therapies when single treatments are insufficient 8
Pediatric Migraine Considerations
Ibuprofen is recommended for children and adolescents with acute migraine. 5
- Triptans for adolescents include sumatriptan/naproxen oral, zolmitriptan nasal, sumatriptan nasal, rizatriptan ODT, or almotriptan oral 5
Concussion-Related Headache
Ibuprofen 400-800mg every 6 hours is first-line treatment for concussion-related headaches. 5
- Naproxen sodium 275-550mg every 2-6 hours provides longer duration 5
Comparative Effectiveness
Insufficient evidence exists to recommend one specific medication over another within the same class for either acute or preventive headache treatment. 4
- Treatment selection should be based on patient-specific factors including comorbidities, contraindications, and prior treatment responses 5, 8
- Robust head-to-head evidence is largely unavailable because phase 3 trials compare new pharmacotherapies versus placebo 4
Comprehensive Management Strategy
Essential Components
- Address lifestyle factors: hydration, regular meals, sufficient sleep, physical activity, and stress management 5
- Identify and avoid migraine triggers 5
- Address comorbid conditions including depression, anxiety, substance abuse, and chronic musculoskeletal pain syndromes that can impair treatment effectiveness 2
- Maintain a headache diary to document frequency, symptoms, initiating/exacerbating conditions, and treatment response over time 2
Follow-Up and Monitoring
- Schedule regular follow-up to monitor progress 2
- Monitor for medication overuse in patients with frequent headaches 8
- Evaluate for adverse effects of preventive medications, particularly anticholinergic effects with amitriptyline 8
- Adjust treatment based on response, considering combination therapies when single treatments are insufficient 8
Referral Indications
Refer to neurology for cluster headache, headache of uncertain diagnosis, poor response to preventive strategies, migraine with persistent aura, or headache with associated motor weakness. 9