What should I do about a frontal headache that wakes me up and is not relieved by naproxen (Aleve) at the usual dose?

Frontal Headache Upon Waking Not Responding to Naproxen

Switch to a triptan (sumatriptan 50–100 mg or rizatriptan 10 mg) immediately at headache onset, because failure of naproxen after adequate trials indicates moderate-to-severe migraine requiring escalation to first-line triptan therapy. 1

Why Naproxen Is Failing

• Naproxen has a number-needed-to-treat (NNT) of 11 for pain-free response at 2 hours, meaning fewer than 2 in 10 patients achieve complete relief—this is not clinically useful as a stand-alone treatment for most migraine sufferers. 2, 3
• Morning headaches that wake you from sleep suggest migraine without aura, and naproxen's modest efficacy (only 17% pain-free vs 8% placebo at 2 hours) explains why it is not working. 2
• If you have used naproxen for 2–3 headache episodes without adequate relief, guidelines explicitly recommend switching to a triptan rather than continuing ineffective therapy. 1

First-Line Triptan Options

• Sumatriptan 50–100 mg taken at the earliest sign of headache (ideally when pain is still mild) provides the strongest evidence for efficacy, with superior pain-free rates compared to NSAIDs alone. 1, 4
• Rizatriptan 10 mg reaches peak concentration in 60–90 minutes, making it the fastest oral triptan and an excellent alternative if sumatriptan fails after 2–3 attempts. 1
• Take the triptan as soon as you wake with the headache—early treatment dramatically improves outcomes (≈50% pain-free at 2 hours when treated early vs ≈28% when delayed). 1

Combination Therapy for Maximum Efficacy

• Adding naproxen 500 mg to your triptan provides synergistic benefit and is superior to either agent alone, with 130 additional patients per 1,000 achieving sustained relief at 48 hours. 1
• This combination (triptan + NSAID) carries the strongest recommendation from 2025 guidelines and should be your go-to strategy for moderate-to-severe attacks. 1

Critical Frequency Limit to Prevent Medication-Overuse Headache

• Limit all acute headache medications to ≤2 days per week (≤10 days per month) to avoid medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 1, 5
• If you need acute treatment more than twice weekly, you must initiate preventive therapy immediately—continuing frequent acute medication use creates a vicious cycle that worsens your headaches. 1, 5

When to Start Preventive Therapy

• Morning headaches that require regular medication meet the threshold for preventive therapy, which is indicated for patients with ≥2 attacks per month causing disability or requiring acute medication >2 days per week. 6, 1
• First-line preventive options include propranolol 80–240 mg/day, topiramate, or amitriptyline 30–150 mg/day, with efficacy requiring 2–3 months to assess. 6, 1

Red Flags Requiring Urgent Evaluation

• Seek immediate care if your headache is accompanied by thunderclap onset, fever with neck stiffness, focal neurological deficits, altered mental status, or progressive worsening—these suggest secondary causes requiring neuroimaging. 1, 5
• New-onset morning headaches after age 50 or headaches that wake you from sleep warrant evaluation to exclude secondary causes, though typical migraine patterns do not require routine imaging. 1

Medications to Absolutely Avoid

• Never use opioids (codeine, hydrocodone, oxycodone) or butalbital-containing compounds for migraine—they have questionable efficacy, cause dependency, trigger rebound headaches, and worsen long-term outcomes. 1, 4

Alternative If Triptans Are Contraindicated

• If you have cardiovascular disease, uncontrolled hypertension, or other triptan contraindications, gepants (ubrogepant 50–100 mg or rimegepant) are safe alternatives without vasoconstriction. 1
• Acetaminophen 1000 mg is the safest option if NSAIDs and triptans are both contraindicated, though it has lower efficacy (NNT 22 for tension-type headache). 1