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Primary Headache Treatment

April 30, 2017

Behavioural management

•Keep a headache diary

•Reduce caffeine intake

•Regular exercise

•Adequate sleep

• Stress reduction


Medications can be used as acute treatment (when needed) or prevention treatment (daily prophylaxis). In chronic migraines (occurring on more than 15 days a month, for over 3 months), prevention medications are used daily for at least 3 months. If effective (50% improvement), the drug may be continued for 6 to 12 months.

Chronic tension-type headache 

Acute treatment: non-steroidal anti-inflammatory drugs (NSAIDS)

Prophylaxis: amitriptyline or topiramate.

Menstrual migraines

Perimenstrual prophylaxis (starting 2 days before the period and continuing during the period), e.g. frovatriptan 2.5 mg twice daily, zolmitriptan 2.5mg three times a day, naproxen 500 mg twice daily or mefenamic acid 500 mg three times a day. Continuous use of the combined contraceptive pill or estrogen patch can also help.

Cluster headache

Acute treatment: subcutaneous sumatriptan 6 mg (maximum two per day) or intranasal zolmitriptan 5 mg or 20mg intranasal sumatriptan (or 10mg zolmitriptan orally); 100% oxygen 12 L/min for 15 min through non-rebreathing mask.

Prophylaxis: verapamil 240-480 mg/day in three divided doses (bridge with 60 mg of prednisone for 5 days, then reduced by 10 mg every 2 days until discontinued)

Acute migraine

Combination therapy: triptan+non-steroidal anti-inflammatory drug (NSAID) or actaminophen+antiemetic

  • Acetaminophen 1000 mg
  • Domperidone 10 mg or metoclopramide 10 mg for nausea

NSAID options:

  • Ibuprofen 400 mg
  • Aspirin 600–900 mg (ideally effervescent)
  • naproxen sodium 500-550 mg
  • Diclofenac 50mg

Triptan options:

  • Oral: eletriptan 40 mg (Relpax), rizatriptan 10 mg (Maxalt), zolmitriptan 2.5 mg, oral sumatriptan 100 mg, , almotriptan 12.5 mg (Axert),  , frovatriptan 2.5 mg, naratriptan 2.5 mg
  • Oral wafer (if fluid ingestion worsens nausea): rizatriptan 10 mg or zolmitriptan 2.5 mg
  • Nasal spray (if nausea): zolmitriptan 5 mg or sumatriptan 20 mg
  • Subcutaneous sumatriptan 6 mg

Triptans should be used, on average, on no more than 2 days per week (10 days per month) to reduce the risk of a triptan-overuse headache. Nasal preparations have a faster onset of action than oral preparations and the subcutaneous injection has the fastest onset.

Medication overuse headaches happen when patients use combination analgesics, opioids, or triptans on ≥ 10 days per month or acetaminophen or NSAIDs on ≥15 days per month.

Migraine prophylaxis

Over the counter options

• butterbur 75 mg twice daily

• riboflavin 400 mg/d

• melatonin 3mg daily

• magnesium citrate 300 mg twice daily

• coenzyme Q10 100 mg 3 times daily

Prescription options

Usually topiramate or a beta blocker.

• topiramate 25mg to 50mg twice daily (useful if the patient is overweight, avoid in depression, can reduce the efficacy of the contraceptive pill)

• propranolol 20-80mg twice daily (avoid in asthma, diabetes, depression, smokers and >60 years of age)

• metoprolol 25-100mg twice daily (avoid in asthma, diabetes, depression, smokers and >60 years of age)

• amitriptyline 10-50mg at bedtime (useful if depression, anxiety, insomnia, or tension-type headache)

• venlafaxine 37.5-150mg/d (consider for migraine in patients with depression)

• gabapentin 300-1800 mg/d

• divalproex 250-500mg twice daily (avoid in pregnancy or when pregnancy is possible)

• candesartan 8-16mg/d

• onabotulinumtoxinA 155-195 units every 3 months for chronic migraines only (headaches on ≥15 days per month)



Doctors secrets …

Headache Impact Test (HIT 6)

Migraine Disabilities Assessment Test (MIDAS)

Hospital Anxiety and Depression Scale (HADS)

Strictly unilateral headache: consider hemicrania continua and conduct a 9-day indomethacin challenge. Headaches should respond to indomethacin 75 mg to 100 mg daily (given in three divided doses) for three days; the dose can then be increased if necessary to a total daily dose of 150 mg for three days, followed if necessary by a total daily dose of 200 mg to 225 mg daily (given in at least three divided doses per day) for three days. Arrange for neuroimaging.


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