What is the recommended treatment for an adult patient with no significant past medical history presenting with an initial frontal headache?

Treatment for Initial Presentation of Frontal Headache

For an adult with no significant past medical history presenting with an initial frontal headache, start with an NSAID (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) or acetaminophen 1000 mg as first-line therapy, and if this provides inadequate relief, add a triptan to the NSAID regimen for optimal efficacy. 1

Critical First Step: Rule Out Secondary Causes

Before initiating treatment, assess for red flags that indicate urgent secondary headache requiring immediate neuroimaging 1:

• Thunderclap onset (abrupt, severe headache reaching maximum intensity within seconds to minutes) 2
• New headache in patient ≥50 years old 1
• Headache worsened by Valsalva maneuver or cough 1
• Headache awakening patient from sleep 1
• Progressive worsening pattern 1
• Abnormal neurologic examination findings 1
• Fever with neck stiffness 3
• History of cancer or immunosuppression 1

If any red flags are present, obtain neuroimaging (MRI preferred, CT if acute trauma or abrupt onset) before initiating treatment. 1, 2 If the neurologic examination is normal and no red flags exist, neuroimaging is usually not warranted. 1

Stepwise Treatment Algorithm

Step 1: First-Line Therapy for Mild to Moderate Headache

Start with NSAIDs or acetaminophen as initial therapy: 1, 3

• Ibuprofen 400-800 mg 1, 3
• Naproxen sodium 500-825 mg 1, 3
• Aspirin 1000 mg 1, 3
• Acetaminophen 1000 mg (when NSAIDs contraindicated) 1

Administer as early as possible during the attack to improve efficacy. 1 The combination of acetaminophen with aspirin and caffeine is more effective than acetaminophen alone. 1

Step 2: Escalation for Moderate to Severe Headache

If NSAIDs or acetaminophen alone provide inadequate relief, add a triptan to the NSAID (or acetaminophen if NSAIDs contraindicated): 1

• Sumatriptan 50-100 mg PLUS naproxen sodium 500 mg is the most evidence-based combination, with 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to triptan alone 1, 4, 3
• Alternative triptans include almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, or zolmitriptan 1
• Combination therapy is superior to either agent alone 1, 4

Counsel patients to begin treatment as soon as possible after headache onset using combination therapy to improve efficacy. 1

Step 3: Alternative Options if Combination Therapy Fails

If the patient does not tolerate or has inadequate response to triptan-NSAID combination, consider: 1

• CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant 1
• Ergot alkaloid: dihydroergotamine (intranasal formulation particularly effective) 1, 4
• Ditan: lasmiditan (reserved for patients who fail all other treatments) 1

Critical Medications to AVOID

Never use opioids or butalbital-containing medications for acute headache treatment. 1, 4 These lead to dependency, rebound headaches, medication overuse headache, and eventual loss of efficacy. 1, 4

Special Considerations for Route of Administration

If severe nausea or vomiting is present: 1

• Use a nonoral triptan (subcutaneous sumatriptan 6 mg provides highest efficacy with onset within 15 minutes) 4, 3
• Add an antiemetic (metoclopramide 10 mg IV or prochlorperazine 10 mg IV) 1, 4

Medication Overuse Headache Prevention

Strictly limit all acute headache medications to no more than 2 days per week to prevent medication overuse headache: 1, 4

• NSAIDs/acetaminophen: ≥15 days per month triggers medication overuse headache 1
• Triptans: ≥10 days per month triggers medication overuse headache 1

If the patient requires acute treatment more than twice weekly, initiate preventive therapy immediately. 1, 4

Lifestyle Modifications

Counsel patients on modifiable factors: 1

• Maintain adequate hydration 1
• Secure regular meals (avoid skipping meals) 1
• Ensure sufficient and consistent sleep 1
• Engage in regular moderate to intense aerobic exercise 1
• Manage stress with relaxation techniques or mindfulness 1
• Identify and avoid specific triggers (certain foods, odors, weather changes) 1

Common Pitfalls to Avoid

Do not assume all frontal headaches are migraine without proper evaluation. 1 Frontal location alone does not confirm migraine diagnosis—assess for associated symptoms (nausea, photophobia, phonophobia) and typical migraine characteristics. 1

Do not allow patients to increase frequency of acute medication use in response to treatment failure. 4, 3 This creates a vicious cycle of medication overuse headache. Instead, transition to preventive therapy while optimizing acute treatment strategy. 4, 3

Do not prescribe acetaminophen alone for migraine treatment. 1 It is only effective in combination with aspirin and caffeine. 1

Ensure patients understand that triptans are contraindicated in ischemic vascular disease, vasospastic coronary disease, uncontrolled hypertension, or significant cardiovascular disease. 3, 5