Treatment of Headache
For acute headache treatment, start with NSAIDs (ibuprofen, aspirin, or diclofenac) as first-line therapy, escalate to triptans if NSAIDs fail, and reserve preventive therapy for patients experiencing more than two headaches per week. 1
Initial Assessment and Red Flags
Before initiating treatment, exclude secondary causes that require urgent evaluation:
- Obtain neuroimaging immediately for thunderclap headache, headache worsened by Valsalva maneuver, headache awakening patient from sleep, new onset in patients over 50 years, progressively worsening pattern, or abnormal neurologic examination 1, 2
- Consider neuroimaging for headaches with atypical features that don't meet strict migraine criteria, even with normal neurologic exam 1
- Evaluate urgently for new headache with fever, meningeal signs, papilledema with focal deficits, impaired consciousness, or concern for acute glaucoma 2
Acute Treatment Algorithm
First-Line: NSAIDs
- Use aspirin, ibuprofen, or diclofenac potassium for mild to moderate headaches 1
- Administer as early as possible during the attack to maximize efficacy 1
- Acetaminophen alone has limited efficacy but works in combination with aspirin and caffeine 1
- Limit use to less than 15 days per month to prevent medication overuse headache 3
Second-Line: Triptans
- Offer triptans when NSAIDs provide inadequate relief 1
- Take early in the attack when headache is still mild for maximum effectiveness 1
- All triptans have well-documented effectiveness; if one fails, try another 1
- Sumatriptan 50-100 mg achieves headache response in 50-62% at 2 hours and 68-79% at 4 hours 4
- Limit use to less than 10 days per month to prevent medication overuse headache 3
Critical contraindications for triptans: uncontrolled hypertension, coronary artery disease, Prinzmetal's angina, history of stroke/TIA, basilar or hemiplegic migraine, Wolff-Parkinson-White syndrome 4
Adjunctive Antiemetic Therapy
- Add metoclopramide 10 mg (oral or IV) for migraine-associated nausea 5, 6
- Consider nonoral routes if vomiting prevents oral medication absorption 5
Preventive Therapy Indications
Initiate preventive therapy if:
- More than two headaches per week 1
- Two or more migraine attacks per month causing disability for 3+ days 5
- Rescue medication use more than twice weekly 5
Preventive Medication Options
- Propranolol is first-line with the best safety data 5, 6
- Amitriptyline if propranolol is contraindicated 5, 6
- Other evidence-based options include topiramate, gabapentin, valproate, and onabotulinumtoxinA, which reduce migraine frequency by 1-3 days per month 3, 7
Medication Overuse Headache
Suspect medication overuse headache in patients with frequent headaches (≥15 days/month) 8
- Overuse is defined as: ≥10 days/month for triptans, ergotamine, or opioids; ≥15 days/month for NSAIDs or acetaminophen 4, 3
- Complete withdrawal of overused medications is necessary 4, 8
- Patients overusing opioids, barbiturates, or benzodiazepines require slow tapering and possibly inpatient treatment 8
- Patients overusing other agents can withdraw more quickly 8
Medications to Avoid
Never use opioids or butalbital-containing medications for headache treatment due to risks of dependency, rebound headaches, and lack of efficacy 6, 8
Special Populations
Pregnancy
- Acetaminophen 1000 mg is first-line 6
- NSAIDs only in second trimester 6
- Sumatriptan may be used sporadically under specialist supervision when other treatments fail 6
- Avoid topiramate, valproate, candesartan, ergotamines, and CGRP antagonists 6
Children
- Ibuprofen is more effective than acetaminophen alone 5
- Triptans contraindicated with uncontrolled hypertension, basilar/hemiplegic migraine, or cardiac risk factors 5
- Propranolol is first-line preventive with best pediatric safety data 5
Lifestyle Modifications
- Maintain consistent sleep schedule with adequate hours 5, 6
- Ensure proper hydration throughout the day 5, 6
- Encourage regular moderate-to-intense aerobic exercise 5
- Use headache diary to identify specific triggers 5