What encouragement and treatment options should be offered to a patient with recurrent headaches (including tension‑type and migraine)?

Management of Recurrent Headaches: Treatment and Encouragement

For patients with recurrent headaches including tension-type and migraine, begin with NSAIDs (ibuprofen, naproxen, or aspirin) as first-line acute therapy, and strongly consider preventive treatment if headaches adversely affect the patient on ≥2 days per month despite optimized acute treatment. 1, 2

Patient Encouragement and Education

Reassure patients that effective treatments exist and that headache-related disability can be substantially reduced with appropriate management. 1

• Emphasize that treatment success requires active patient participation through tracking headaches with a diary, identifying triggers, and adhering to both acute and preventive regimens. 1, 2
• Set realistic expectations: therapeutic benefits from preventive medications typically emerge over 2-3 months, not immediately. 1, 2
• Counsel patients on lifestyle modifications including adequate hydration, regular meals, consistent sleep schedules, regular aerobic exercise, stress management, and weight control if overweight. 2, 3
• Explain that migraine is underdiagnosed and when choosing between primary headache types, it is reasonable to err on the side of migraine diagnosis, as this opens more treatment options. 4

Acute Treatment Algorithm

For Mild to Moderate Attacks

• Start with NSAIDs (aspirin, ibuprofen 400mg, or naproxen) or the combination of aspirin + acetaminophen + caffeine. 1
• Administer as early as possible during an attack to improve efficacy. 1
• Acetaminophen alone is NOT recommended for migraine; it must be combined with aspirin and caffeine to be effective. 1
• For tension-type headache specifically: ibuprofen 400mg or acetaminophen 1000mg are appropriate. 1

For Moderate to Severe Attacks or NSAID Failures

• Use triptans (sumatriptan, rizatriptan, zolmitriptan, or naratriptan) combined with an NSAID or acetaminophen as first-line therapy. 1, 2
• Ensure adequate NSAID/acetaminophen dosing before adding a triptan—this is a common pitfall that reduces treatment success. 2
• If one triptan fails, try a different triptan before abandoning this class; patients may respond to one but not another. 1, 2
• Subcutaneous sumatriptan reaches peak concentration fastest (15 minutes) and is effective in 70-82% of patients. 1

For Attacks with Nausea/Vomiting

• Use non-oral routes: subcutaneous or intranasal sumatriptan, rizatriptan wafers, or intranasal DHE. 1
• Add an antiemetic (metoclopramide or prochlorperazine) to treat nausea itself, which is disabling even without vomiting. 1

Second-Line Acute Options

• CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant if triptans fail or are contraindicated. 1, 2
• Dihydroergotamine (DHE) nasal spray or parenteral formulations for severe migraines. 1

Third-Line Acute Options

• Lasmiditan (a ditan) when second-line agents fail. 2

Rescue Therapy for Severe Refractory Attacks

• Ketorolac (parenteral NSAID) has rapid onset and is reserved for severe migraines with low rebound risk. 1
• Opioids (meperidine, butorphanol) are expressly contraindicated for routine migraine treatment due to dependency risk, rebound headaches, and loss of efficacy. 1, 2
• Avoid butalbital-containing products for the same reasons. 1, 2

Preventive Treatment Indications

Initiate preventive therapy when any of the following apply: 1, 2

• Headaches adversely affect the patient on ≥2 days per month despite optimized acute treatment
• Two or more attacks per month producing disability lasting ≥3 days
• Contraindication to or failure of acute treatments
• Use of acute medication more than twice per week (to prevent medication-overuse headache)
• Presence of uncommon migraine variants (hemiplegic migraine, prolonged aura, migrainous infarction)

Preventive Treatment Algorithm

First-Line Preventive Medications

For episodic migraine: 1

• Beta-blockers: propranolol (80-240mg/day), timolol (20-30mg/day), atenolol, bisoprolol, or metoprolol
• Topiramate (64-1500mg/day)
• Candesartan (angiotensin-receptor blocker)

Alternative first-line options: 1, 2

• Lisinopril (ACE inhibitor)
• Telmisartan (ARB)

Second-Line Preventive Medications

• Amitriptyline (30-150mg/day) 1
• Flunarizine 1
• Sodium valproate (800-1500mg/day) in men only—strictly contraindicated in women of childbearing potential 1

For chronic tension-type headache prevention: amitriptyline is the medication with strongest evidence. 1, 5

Third-Line Preventive Medications

• CGRP monoclonal antibodies: erenumab, fremanezumab, galcanezumab, or eptinezumab for patients who have failed first- and second-line options. 1, 2
• Atogepant (oral CGRP antagonist) 2
• OnabotulinumtoxinA for chronic migraine (≥15 headache days/month) but NOT for episodic migraine. 1
• Gabapentin is NOT recommended for episodic migraine prevention. 1

Preventive Therapy Principles

• Start low, titrate slowly to the target dose over weeks. 2
• Allow 2-3 months before deeming a preventive agent ineffective. 1, 2
• Reevaluate regularly and consider pausing preventive therapy after 6-12 months of good control. 1

Non-Pharmacologic Interventions

These can be used as adjuncts to medications or as stand-alone therapy when medications are contraindicated: 1

• Aerobic exercise has evidence supporting its use for both migraine and tension-type headache. 1, 6
• Biobehavioral therapies: cognitive behavioral therapy (CBT), biofeedback, relaxation training, and mindfulness-based therapies show efficacy approaching that of preventive medications. 3, 6, 7
• Acupuncture has positive evidence from randomized trials for migraine prevention. 1, 6, 7
• Physical therapy can be used for tension-type headache and migraine management. 1
• Neuromodulatory devices (transcranial magnetic stimulation, vagus nerve stimulation, trigeminal nerve stimulation) may be appropriate for acute or preventive treatment. 1, 8

Group delivery of interventions appears more effective than one-to-one delivery, and interventions including CBT, mindfulness, and explicit educational components show larger effects. 3

Critical Warnings: Medication-Overuse Headache (MOH)

MOH occurs with headache on ≥15 days/month for ≥3 months attributable to acute medication overuse: 2

• NSAIDs: overuse threshold is ≥15 days/month
• Triptans: overuse threshold is ≥10 days/month
• Closely monitor analgesic use as overuse leads to rebound headaches and transformation to chronic daily headache. 1

Special Populations

• Discuss potential adverse effects of all migraine medications with patients of childbearing potential before prescribing. 2
• In older patients, consider cardiovascular comorbidities before prescribing triptans, which are contraindicated in ischemic vascular disease, vasospastic coronary disease, and uncontrolled hypertension. 1

Cost Considerations

When clinically appropriate, select less expensive recommended medications: 2

• Oral CGRP antagonists (gepants) cost approximately $4,959-$5,994 annually
• Intranasal gepants cost approximately $8,800 annually
• Generic triptans and older preventive medications (propranolol, topiramate, amitriptyline) are substantially less expensive

Cost should be factored into treatment selection when multiple options have comparable efficacy. 2