What are the recommended treatments for headaches?

Headache Treatment

For acute migraine headaches, start with combination therapy of a triptan (sumatriptan 50-100 mg) plus an NSAID (naproxen 500 mg or ibuprofen 400 mg) for moderate to severe attacks, or NSAID monotherapy for mild to moderate attacks, taken as early as possible at headache onset. 1

First-Line Treatment Algorithm

Mild to Moderate Migraine

• Start with NSAID monotherapy: ibuprofen 400 mg, naproxen 500-825 mg, or aspirin 1000 mg 1
• Acetaminophen 1000 mg is an alternative if NSAIDs are contraindicated 1
• Take medication immediately at headache onset while pain is still mild for maximum effectiveness 1

Moderate to Severe Migraine

• Use combination therapy: triptan + NSAID 1
  • Sumatriptan 50-100 mg PLUS naproxen 500 mg provides superior efficacy compared to either agent alone 1
  • This combination results in 130 more patients per 1000 achieving sustained pain relief at 48 hours 1
• Alternative triptans include rizatriptan, zolmitriptan, or naratriptan 1

Severe Migraine with Nausea/Vomiting

• Use non-oral routes: subcutaneous sumatriptan 6 mg provides the highest efficacy with onset within 15 minutes, achieving pain relief in 70-82% of patients 1, 2
• Add an antiemetic: metoclopramide 10 mg or prochlorperazine 10 mg, which provide direct analgesic effects beyond treating nausea 1

Second-Line Options (When First-Line Fails or Is Contraindicated)

CGRP Antagonists (Gepants)

• Rimegepant, ubrogepant, or zavegepant for patients who do not tolerate or have inadequate response to triptan + NSAID combination 1
• These are less effective than triptan combinations but useful when triptans are contraindicated (cardiovascular disease, uncontrolled hypertension) 1

Ergot Alkaloids

• Dihydroergotamine (intranasal or IV) for patients with contraindications to triptans 1

Ditans

• Lasmiditan for patients who have failed all other treatments in this guideline 1

Tension-Type Headache Treatment

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

Cluster Headache Treatment

• Subcutaneous sumatriptan 6 mg or intranasal zolmitriptan 10 mg for acute cluster headache attacks 1
• Normobaric oxygen therapy is also effective 1
• Galcanezumab for prevention of episodic cluster headache (not chronic) 1

Critical Frequency Limitation to Prevent Medication-Overuse Headache

Limit ALL acute headache medications to no more than 2 days per week 1

• Using triptans ≥10 days per month or NSAIDs ≥15 days per month causes medication-overuse headache, leading to daily headaches 1
• If needing acute treatment more than twice weekly, initiate preventive therapy immediately 1

Medications to AVOID

Do not use opioids or butalbital-containing compounds for migraine treatment 1

• These medications lead to dependency, rebound headaches, and eventual loss of efficacy 1
• They should only be considered as absolute last resort when all other options are contraindicated and abuse risk has been addressed 1

IV Treatment for Emergency/Urgent Care Settings

The most effective IV cocktail combines: 1, 3

• Metoclopramide 10 mg IV (provides direct analgesic effects through dopamine receptor antagonism) 3
• Ketorolac 30 mg IV (rapid onset, 6-hour duration, minimal rebound risk) 3

Alternative IV option: Dihydroergotamine (DHE) 1, 3

Special Populations

Pregnancy and Breastfeeding

• Discuss adverse effects of all pharmacologic treatments during pregnancy and lactation before prescribing 1
• Avoid valproate due to teratogenic risk 1

Cardiovascular Disease

• Triptans are contraindicated in ischemic vascular disease, vasospastic coronary disease, and uncontrolled hypertension 1, 2
• Use CGRP antagonists or NSAIDs instead 1

When to Initiate Preventive Therapy

Preventive therapy is indicated when: 1

• Two or more attacks per month producing disability lasting 3+ days 1
• Using acute medications more than 2 days per week 1
• Contraindication to or failure of acute treatments 1
• Presence of medication-overuse headache 1

First-line preventive options include propranolol, topiramate, or amitriptyline 1

Common Pitfalls to Avoid

1. Delaying treatment: Triptans and NSAIDs work best when taken early in the attack while pain is still mild 1
2. Underdosing: Ibuprofen 400 mg is more effective than 200 mg; sumatriptan 50-100 mg is more effective than 25 mg 1, 2, 4
3. Monotherapy for moderate-severe migraine: Combination therapy (triptan + NSAID) is superior to either agent alone 1
4. Frequent acute medication use: This creates medication-overuse headache, worsening the problem 1
5. Using opioids: These worsen long-term outcomes and should be avoided 1