Management of Headache

Publication Date: October 1, 2023
Last Updated: October 12, 2023

Medication Overuse Headache Screening and Other Considerations

We suggest providers assess for and consider the following high-risk factors for medication overuse headache in patients with headache (in order of relative impact):
  • Headache frequency (greater than or equal to 7 days per month)
  • Migraine diagnosis
  • Medication use: frequent use of anxiolytics, analgesics (for any condition, including use of opioids or non-opioid analgesics for acute treatment of migraine), or sedative hypnotics
  • History of anxiety or depression, especially in combination with musculoskeletal complaints or gastrointestinal complaints
  • Physical inactivity
  • Sick leave of greater than 2 weeks in the last year
  • Self-reported whiplash
  • Smoking (tobacco use)
(Weak for)
315659

Pharmacotherapy

Headache - Preventive

There is insufficient evidence to recommend for or against coenzyme Q10, feverfew, melatonin, omega-3, vitamin B2, or vitamin B6 for the prevention of headache. (Neither for or against)
315659
There is insufficient evidence to recommend for or against fluoxetine or venlafaxine for the prevention of headache. (Neither for or against)
315659

Migraine - Preventive

We recommend candesartan or telmisartan for the prevention of episodic migraine. (Strong for)
315659
We recommend erenumab, fremanezumab, or galcanezumab for the prevention of episodic or chronic migraine. (Strong for)
315659
We suggest intravenous eptinezumab for the prevention of episodic or chronic migraine. (Weak for)
315659
We suggest lisinopril for the prevention of episodic migraine. (Weak for)
315659
We suggest oral magnesium for the prevention of migraine. (Weak for)
315659
We suggest topiramate for the prevention of episodic and chronic migraine. (Weak for)
315659
We suggest propranolol for the prevention of migraine. (Weak for)
315659
We suggest valproate for the prevention of episodic migraine. (Weak for)
315659
We suggest memantine for the prevention of episodic migraine. (Weak for)
315659
We suggest atogepant for the prevention of episodic migraine. (Weak for)
315659
We suggest onabotulinumtoxinA injection for the prevention of chronic migraine. (Weak for)
315659
We suggest against abobotulinumtoxinA or onabotulinumtoxinA injection for the prevention of episodic migraine. (Weak against)
315659
There is insufficient evidence to recommend for or against rimegepant for the prevention of episodic migraine. (Neither for or against)
315659
We suggest against the use of gabapentin for the prevention of episodic migraine. (Weak against)
315659
There is insufficient evidence to recommend for or against levetiracetam for the prevention of episodic migraine. (Neither for or against)
315659

Migraine - Abortive

We recommend eletriptan, frovatriptan, rizatriptan, sumatriptan (oral or subcutaneous), the combination of sumatriptan and naproxen, or zolmitriptan (oral or intranasal) for the acute treatment of migraine. (Strong for)
315659
We recommend aspirin/acetaminophen/caffeine for the acute treatment of migraine. (Strong for)
315659
We suggest acetaminophen, aspirin, ibuprofen, or naproxen for the acute treatment of migraine. (Weak for)
315659
We suggest rimegepant or ubrogepant for the acute treatment of migraine. (Weak for)
315659
We suggest against intravenous ketamine for the acute treatment of migraine. (Weak against)
315659
There is insufficient evidence to recommend for or against lasmiditan for the acute treatment of migraine. (Neither for or against)
315659

Tension-Type Headache - Preventive

We suggest amitriptyline for the prevention of chronic tension-type headache. (Weak for)
315659
We suggest against botulinum/neurotoxin injection for the prevention of chronic tension-type headache. (Weak against)
315659

Tension-Type Headache - Abortive

We suggest ibuprofen (400 mg) or acetaminophen (1,000 mg) for the acute treatment of tension-type headache. (Weak for)
315659

Cluster Headache - Preventive

We suggest galcanezumab for the prevention of episodic cluster headache. (Weak for)
315659
We suggest against galcanezumab for the prevention of chronic cluster headache. (Weak against)
315659
There is insufficient evidence to recommend for or against verapamil for the prevention of episodic or chronic cluster headache. (Neither for or against)
315659

Cluster Headache - Abortive

We suggest subcutaneous sumatriptan (6 mg) or intranasal zolmitriptan (10 mg) for the acute treatment of cluster headache. (Weak for)
315659
We suggest the use of normobaric oxygen therapy for the acute treatment of cluster headache. (Weak for)
315659

Medication Overuse Headache

There is insufficient evidence to recommend for or against the addition of any specific preventive agent or withdrawal strategy to guide the treatment of medication overuse headache. (Neither for or against)
315659

Injections, Procedures, and Invasive Interventions

We suggest greater occipital nerve block for the acute treatment of migraine. (Weak for)
315659

There is insufficient evidence to recommend for or against greater occipital nerve block for the prevention of chronic migraine. (Neither for or against)
315659

There is insufficient evidence to recommend for or against supra orbital nerve block for acute treatment of migraine. (Neither for or against)
315659

There is insufficient evidence to recommend for or against intravenous antiemetics (i.e., intravenous chlorpromazine, intravenous metoclopramide, intravenous prochlorperazine), intravenous magnesium, or intranasal lidocaine for the acute treatment of headache. (Neither for or against)
315659

There is insufficient evidence to recommend for or against pulsed radiofrequency procedure of the upper cervical nerves or sphenopalatine ganglion block for the treatment of chronic migraine. (Neither for or against)
315659

We suggest against an implantable sphenopalatine ganglion stimulator for the treatment of cluster headache. (Weak against)
315659

We suggest against patent foramen ovale closure for the treatment or prevention of migraine. (Weak against)
315659

Non-pharmacologic Therapy

We suggest non-invasive vagus nerve stimulation for the acute treatment of episodic cluster headache. (Weak for)
315659

We suggest physical therapy for the management of tension-type, migraine, or cervicogenic headache. (Weak for)
315659

We suggest aerobic exercise or progressive strength training for the prevention of tension-type and migraine headache. (Weak for)
315659

There is insufficient evidence to recommend for or against the following behavioral interventions for the treatment and/or prevention of headache:
  • Biofeedback and smartphone application-based heartrate variability monitoring
  • Cognitive behavioral therapy
  • Mindfulness-based therapies
  • Progressive muscle relaxation
(Neither for or against)
315659

There is insufficient evidence to recommend for or against acupuncture, dry needling, or yoga for the treatment and/or prevention of headache. (Neither for or against)
315659

There is insufficient evidence to recommend for or against dietary trigger avoidance for the prevention of headache. (Neither for or against)
315659

We suggest against immunoglobulin G antibody testing for dietary trigger avoidance for the prevention of headache. (Weak against)
315659

There is insufficient evidence to recommend for or against any form of neuromodulation for the treatment and/or prevention of migraine:
  • Non-invasive vagus nerve stimulation
  • Supraorbital, or external trigeminal, nerve stimulation
  • Remote electrical neurostimulation
  • External combined occipital and trigeminal neurostimulation system
  • Repetitive transcranial magnetic stimulation
  • Transcranial direct current stimulation
(Neither for or against)
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Comparative Effectiveness and Combination Therapies

There is insufficient evidence to recommend for or against choosing a specific treatment strategy for posttraumatic headache. (Neither for or against)
315659

There is insufficient evidence to recommend for or against any specific medication over another for the acute treatment of migraine. (Neither for or against)
315659

There is insufficient evidence to recommend for or against any specific medication over another for the prevention of migraine headache, tension headache, or cluster headache. (Neither for or against)
315659

There is insufficient evidence to recommend for or against any specific combination of therapies for the prevention of headache. (Neither for or against)
315659

Recommendation Grading

Overview

Title

Management of Headache

Authoring Organization

Publication Month/Year

October 1, 2023

Last Updated Month/Year

February 6, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management

Diseases/Conditions (MeSH)

D006261 - Headache, D020773 - Headache Disorders, D014493 - United States Department of Veterans Affairs, D058014 - Veterans Health, D000081324 - Veterans Health Services

Keywords

headache, veteran

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
388
Literature Search Start Date
March 6, 2019
Literature Search End Date
August 16, 2022