What is the recommended treatment for a general adult patient presenting with headaches, considering their medical history and potential underlying causes?

Headache Treatment in Adults

Immediate Treatment Algorithm for Acute Migraine

For moderate to severe migraine headaches, start with combination therapy of a triptan plus an NSAID (such as sumatriptan 50-100 mg with naproxen 500 mg), which provides sustained pain relief in 130 more patients per 1000 compared to triptan alone. 1, 2

First-Line Treatment Options

• Combination therapy (triptan + NSAID) is the most effective initial approach for nonpregnant adults with moderate to severe migraine presenting in outpatient or urgent care settings 1, 2
• Specific recommended combinations include:
  • Sumatriptan 50-100 mg + naproxen 500 mg 2
  • Alternative NSAIDs if naproxen unavailable: aspirin, celecoxib, diclofenac, or ibuprofen 1, 3
• For patients intolerant to NSAIDs: combine a triptan with acetaminophen 1000 mg, though evidence is lower certainty 1, 2

NSAID Monotherapy for Mild-Moderate Headache

• For mild to moderate migraine or tension-type headache, start with NSAID monotherapy before escalating to combination therapy 1, 3
• Effective first-line NSAIDs include:
  • Ibuprofen 400 mg (provides 2-hour headache relief in 57% vs 25% with placebo, NNT 3.2) 4
  • Diclofenac potassium 50-100 mg 3
  • Naproxen 500 mg 2
• Acetaminophen 1000 mg is less effective (NNT 5.0 for 2-hour headache relief) but appropriate for patients with NSAID contraindications 5, 6

When to Escalate Treatment

• If adequate-dose NSAID monotherapy fails after 2-3 consecutive headache episodes, add a triptan rather than switching between NSAIDs 1, 3
• Second-line options for refractory cases:
  • CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant 2, 7
  • Dihydroergotamine (DHE), particularly effective in intranasal formulation 2
  • Lasmiditan (5-HT1F agonist), safe in patients with cardiovascular risk factors 7

Critical Medications to AVOID

• Never use opioids or butalbital-containing medications for acute migraine due to risks of dependency, rebound headaches, and medication overuse headache 1, 2, 3

Medication Overuse Headache Prevention

• Limit triptan use to <10 days per month 2, 8
• Limit NSAID/acetaminophen use to <15 days per month 2, 8, 3
• Patients exceeding these thresholds require preventive therapy evaluation 8

Indications for Preventive Therapy

• Consider preventive treatment for patients experiencing ≥2 migraine days per month with significant disability despite optimized acute treatment 1, 8
• Patients using acute medications more than twice per week should be evaluated for prevention 8

First-Line Preventive Medications

• Beta-blockers: propranolol 80-240 mg/day or metoprolol 1, 8
• Topiramate: 50-100 mg/day (particularly beneficial in patients with obesity due to weight loss effects) 1, 8
• Candesartan: 16-32 mg/day (especially useful with comorbid hypertension) 1, 8

Second-Line Preventive Medications

• Amitriptyline: 30-150 mg/day (optimal for comorbid depression/anxiety or mixed migraine-tension headache) 1, 8
• Flunarizine: 5-10 mg once daily at night (where available, comparable efficacy to propranolol) 1, 8
• Sodium valproate: 800-1500 mg/day - strictly contraindicated in women of childbearing potential due to teratogenic effects 1, 8

Third-Line: CGRP Monoclonal Antibodies

• Consider erenumab, fremanezumab, galcanezumab, or eptinezumab when first- and second-line preventive treatments have failed or are contraindicated 1, 8
• Require 3-6 months for adequate efficacy assessment 8
• Significantly more expensive ($5,000-$6,000 annually) than oral agents 8

Implementation Strategy for Preventive Therapy

• Start with low doses and titrate slowly until clinical benefits achieved or side effects limit increases 1, 8
• Allow adequate trial period of 2-3 months before determining efficacy 1, 8
• Use headache diaries to track attack frequency, severity, duration, and treatment response 1, 8
• Consider tapering or discontinuing preventive treatment after 6-12 months of successful therapy 8

Special Populations

Pregnant Patients

• Acetaminophen 1000 mg is first-line treatment 2
• Metoclopramide 10 mg is safe and effective for migraine-associated nausea, particularly in second and third trimesters 2
• Triptans and NSAIDs have restrictions during pregnancy 2

Older Adults

• Suspect secondary headache in apparent late-onset migraine (after age 50) 1
• Consider higher risks of cardiovascular disease, comorbidities, and adverse events 1
• Monitor blood pressure regularly in older patients using triptans 1

Children and Adolescents

• Bed rest alone may suffice for short-duration attacks 1
• Ibuprofen is recommended as first-line medication when needed 1
• Preventive options include propranolol, amitriptyline, or topiramate 1

Common Pitfalls to Avoid

• Failing to recognize medication overuse headache from frequent acute medication use (≥10 days/month for triptans, ≥15 days/month for NSAIDs) 8
• Inadequate duration of preventive trial (less than 2-3 months) 8
• Starting preventive medications at too high a dose, leading to poor tolerability and discontinuation 8
• Using subtherapeutic doses of acute medications (ensure ibuprofen ≥400 mg, diclofenac 50-100 mg) 3
• Prescribing opioids or butalbital compounds, which worsen long-term outcomes 1, 2, 3

Non-Pharmacological Adjuncts

• Neuromodulatory devices, biobehavioral therapy (cognitive behavioral therapy, biofeedback), and acupuncture can be used as adjuncts or stand-alone treatments when medications are contraindicated 1, 8
• Limited evidence exists for physical therapy, spinal manipulation, and dietary approaches 1
• Lifestyle modifications: adequate hydration, regular meals, consistent sleep patterns, stress management, and trigger identification 2, 8

Urgent Care/Emergency Department Considerations

• Provide quiet, dark environment and ensure adequate hydration with IV fluids 2
• Counsel patients to begin treatment as soon as possible after migraine onset to improve efficacy 2
• Discharge with acetaminophen 1000 mg for home rescue medication, avoiding opioids or butalbital 2