Medication for headache
Reading File
Finding Sources
Finding Sources
Reading File
Reading File
Reading File
Reading File
Loading Image
Reading File
I now have comprehensive information from authoritative textbooks (Goldman-Cecil Medicine and Bradley & Daroff's Neurology). Here is a thorough, well-organized answer:
Medications for Headache
Headache treatment depends on the type (tension, migraine, cluster) and severity of the attack. There are two main categories: acute (abortive) treatments and preventive treatments.
Approach to Diagnosis First
The flowchart below (from Goldman-Cecil Medicine) guides initial management:
Warning signs requiring urgent evaluation (MRI preferred):
- Fever + headache
- New neurological signs/symptoms
- Thunderclap headache (peak pain within 1 minute)
- Provoked by sexual activity
- New onset after age 50 (consider giant cell arteritis)
1. Acute (Abortive) Treatment
Mild Attacks - Non-Specific Analgesics
| Drug | Dose | Notes |
|---|---|---|
| Acetaminophen (Paracetamol) | 650-1000 mg | First-line OTC |
| Aspirin | 250-1000 mg | Also has anti-inflammatory action |
| Ibuprofen | 400-600 mg | NSAID; effective for tension + migraine |
| Naproxen | 500-825 mg | Longer-acting NSAID |
| Diclofenac | 50 mg | NSAID option |
| Ketoprofen | 75 mg | NSAID option |
Caffeine added to analgesics aids absorption, induces mild vasoconstriction, and enhances efficacy. Combination preparations (e.g., aspirin + acetaminophen + caffeine) are commonly used.
Start treatment as early as possible - once a migraine is fully developed, oral absorption decreases due to reduced GI motility. - Bradley & Daroff's Neurology in Clinical Practice
Moderate to Severe Attacks - Migraine-Specific Drugs
Triptans (5-HT1B/1D agonists) - Grade A Evidence
| Triptan | Routes Available |
|---|---|
| Sumatriptan | Oral, SC injection, intranasal |
| Zolmitriptan | Oral, intranasal |
| Rizatriptan | Oral |
| Naratriptan | Oral |
| Almotriptan | Oral |
| Eletriptan | Oral |
| Frovatriptan | Oral (longest half-life; useful for menstrual migraine) |
Contraindications to triptans: Uncontrolled hypertension, ischemic heart disease, Prinzmetal angina.
Newer Alternatives to Triptans
- Lasmiditan (50-200 mg) - selective 5-HT1F agonist, no vasoconstrictive effects, safe when triptans are contraindicated. Note: sedating - avoid driving for at least 8 hours.
- Rimegepant (75 mg) - CGRP receptor antagonist (gepant); ~10% absolute increase in pain freedom vs placebo at 2 hours. Also approved for prevention (75 mg every other day).
- Ubrogepant (50-100 mg) - another gepant option when triptans fail or are contraindicated.
Ergot Derivatives
- Dihydroergotamine (DHE): 1-2 mg intranasal or SC; 0.5-1 mg IV (requires antiemetic pre-treatment)
- Ergotamine tartrate: 2 mg sublingual or 1-2 mg oral - effective if taken early
Very Severe / Refractory Attacks
| Drug | Dose/Route | Notes |
|---|---|---|
| Ketorolac | 60 mg IM / 30 mg IV | IV NSAID |
| Prochlorperazine | 10-25 mg IM / 10 mg IV | Dopamine D2 antagonist + antiemetic |
| Metoclopramide | 10 mg IV | Antiemetic + prokinetic |
| DHE + antiemetic | IV/SC | Gold standard for refractory attacks |
| Celecoxib solution | 120 mg oral | COX-2 inhibitor |
Opioids should NOT be used except as a last resort, and oral opiates should not be used for chronic recurrent primary headaches. Opioid overuse leads to medication overuse headache (rebound). - Goldman-Cecil Medicine
2. Preventive (Prophylactic) Treatment
Indicated when headaches interfere with activities 3 or more days per month, or are severe/prolonged.
| Drug Class | Examples | Dose | Notes |
|---|---|---|---|
| Beta-blockers | Propranolol, nadolol, timolol | Propranolol 20-80 mg | First-line for migraine; caution in asthma, low BP |
| Calcium-channel blockers | Verapamil, amlodipine | Verapamil 120-480 mg/day | Also used for cluster headache |
| NSAIDs | Naproxen, ibuprofen | Naproxen 200-600 mg/day | Menstrual migraine; GI side effects |
| Indomethacin | 25-50 mg TID | Drug of choice for paroxysmal hemicrania & hemicrania continua | |
| Tricyclic antidepressants | Amitriptyline, nortriptyline | Low doses | Tension-type + migraine prevention |
| Anticonvulsants | Valproate, topiramate | Varies | Valproate: avoid in women of childbearing age |
| CGRP monoclonal antibodies | Erenumab, fremanezumab, eptinezumab, galcanezumab | Monthly SC / quarterly | Modern biologics; highly effective |
| Small-molecule gepants | Atogepant, rimegepant | Daily/alternate-day | Oral CGRP inhibitors for prevention |
| OnabotulinumtoxinA | Botox | Injections every 12 weeks | FDA-approved for chronic migraine only |
3. Adjunct & Special Situations
- Antiemetics (metoclopramide 10 mg, promethazine 25 mg, prochlorperazine 10 mg) - often needed alongside other agents when nausea/vomiting is present
- Cluster headache: High-flow 100% oxygen (gold standard acute), SC sumatriptan, intranasal zolmitriptan; verapamil for prevention
- Pregnancy: Acetaminophen is safest; avoid NSAIDs and triptans if possible; refer to headache specialist
- Tension-type headache: Simple analgesics (paracetamol, ibuprofen); amitriptyline for prevention
- Non-pharmacological: Neuromodulation devices (vagus nerve stimulation, TMS), biofeedback, acupuncture, rest in a dark/quiet room with ice pack
Key Caution: Medication Overuse Headache (MOH)
Using acute medications on >10-15 days/month (especially opioids, triptans, ergotamines, and combination analgesics) can cause chronic daily rebound headache. Patients who smoke are particularly susceptible. Always limit acute medication frequency to prevent this.
Sources: Goldman-Cecil Medicine, 2-Volume Set; Bradley and Daroff's Neurology in Clinical Practice
Disclaimer: This is for educational purposes only. Always consult a healthcare professional for diagnosis and personalized treatment.
This is a shared conversation. Sign in to Orris to start your own chat.