Primary Care Management of Headache
Publication Date: July 1, 2020
Recommendations
| Recommendation | Strength |
| Screening and Healthcare Settings | |
| We suggest providers assess the following risk factors for medication overuse headache in patients with headache: · Medication use: frequent use of anxiolytics, analgesics, or sedative hypnotics · Physical inactivity · Self-reported whiplash · History of anxiety or depression with or without musculoskeletal complaints and/or gastrointestinal complaints · Sick leave of greater than two weeks in the last year · Smoking |
Weak for |
| There is insufficient evidence to recommend for or against any specific strategy or healthcare setting for the withdrawal of medication in the treatment of | Neither for nor against |
| Non-Pharmacologic Therapy | |
| We suggest physical therapy for the management of tension-type headache. | Weak for |
| We suggest aerobic exercise or progressive strength training for the management of headache. | Weak for |
| We suggest mindfulness-based therapies for the treatment of headache. | Weak for |
| We suggest education regarding dietary trigger avoidance for the prevention of migraine. | Weak for |
| We suggest non-invasive vagus nerve stimulation for the acute treatment of episodic cluster headache. | Weak for |
| There is insufficient evidence to recommend for or against acupuncture for the treatment of headache. | Neither for nor against |
| There is insufficient evidence to recommend for or against dry needling for the treatment of headache. | Neither for nor against |
| There is insufficient evidence to recommend for or against pulsed radiofrequency or sphenopalatine ganglion block for the treatment of headache. | Neither for nor against |
| There is insufficient evidence to recommend for or against cognitive behavioral therapy or biofeedback for the treatment of headache. | Neither for nor against |
| There is insufficient evidence to recommend for or against an elimination diet based on immunoglobulin G antibody test results for the prevention of headache. | Neither for nor against |
| There is insufficient evidence to recommend for or against the following for headache: · Transcranial magnetic stimulation · Transcranial direct current stimulation · External trigeminal nerve stimulation · Supraorbital electrical stimulation |
Neither for nor against |
| Pharmacotherapy | |
| We recommend candesartan or telmisartan for the prevention of episodic or chronic migraine. | Strong for |
| We suggest erenumab, fremanezumab, or galcanezumab for the prevention of episodic or chronic migraine. | Weak for |
| We suggest lisinopril for the prevention of episodic migraine. | Weak for |
| We suggest oral magnesium for the prevention of migraine. | Weak for |
| We suggest topiramate for the prevention of episodic migraine. | Weak for |
| We suggest propranolol for the prevention of migraine. | Weak for |
| We suggest onabotulinumtoxinA injection for the prevention of chronic migraine. | Weak for |
| We suggest against abobotulinumtoxinA or onabotulinumtoxinA injection for the prevention of episodic migraine. | Weak against |
| There is insufficient evidence to recommend for or against gabapentin for the prevention of episodic migraine. | Neither for nor against |
| There is insufficient evidence to recommend for or against nimodipine or nifedipine for the prevention of episodic migraine. | Neither for nor against |
| There is insufficient evidence to recommend for or against coenzyme Q10, feverfew, melatonin, omega-3, vitamin B2, or vitamin B6 for the prevention of migraine. | Neither for nor against |
| There is insufficient evidence to recommend for or against combination pharmacotherapy for the prevention of migraine. | Neither for nor against |
| We recommend sumatriptan (oral or subcutaneous), the combination of sumatriptan/naproxen, or zolmitriptan (oral or intranasal) for the acute treatment of migraine. | Strong for |
| We suggest frovatriptan or rizatriptan for the acute treatment of migraine. | Weak for |
| We suggest triptans instead of opioids or non-opioid analgesics to lower the risk of medication overuse headache for the acute treatment of migraine. | Weak for |
| We suggest ibuprofen, naproxen, aspirin, or acetaminophen for the acute treatment of migraine. | Weak for |
| We suggest greater occipital nerve block for the acute treatment of migraine. | Weak for |
| We suggest intravenous magnesium for the acute treatment of migraine. | Weak for |
| We suggest amitriptyline for the prevention of chronic tension-type headache. | Weak for |
| We suggest against botulinum/neurotoxin injection for the prevention of chronic tension-type headache. | Weak against |
| We suggest ibuprofen (400 mg) or acetaminophen (1,000 mg) for the acute treatment of tension-type headache. | Weak for |
| We suggest galcanezumab for the prevention of episodic cluster headache. | Weak for |
| There is insufficient evidence to recommend for or against any particular medication for the acute treatment of cluster headache. | Neither for nor against |
| There is insufficient evidence to recommend for or against oxygen therapy for the acute treatment of primary headache. | Neither for nor against |
| There is insufficient evidence to recommend for or against valproate for the prevention of headache. | Neither for nor against |
| There is insufficient evidence to recommend for or against fluoxetine or venlafaxine for the prevention of headache. | Neither for nor against |
| We suggest against intravenous ketamine for the acute treatment of headache. | Weak against |
| There is insufficient evidence to recommend for or against intravenous metoclopramide, intravenous prochlorperazine, or intranasal lidocaine for the acute treatment of headache. | Neither for nor against |
| There is insufficient evidence to recommend for or against prescription or non- prescription pharmacologic agents for the treatment of secondary headache. | Neither for nor against |
a For more information regarding regarding the scope of the CPG, please refer to Scope of this Clinical Practice Guideline in the full text Headache CPG
b For additional information, please refer to Grading Recommendations in the full text Headache CPG
* The category for all recommendations is Reviewed, New-added. For additional information on recommendation categories, please refer to Recommendation Categorization and Appendix B in the full text Headache CPG
b For additional information, please refer to Grading Recommendations in the full text Headache CPG
* The category for all recommendations is Reviewed, New-added. For additional information on recommendation categories, please refer to Recommendation Categorization and Appendix B in the full text Headache CPG
Algorithm
Evaluation and Treatment of Headache
Sidebar 1: General History and Physical Exam
| Headache history · Frequency · Character · Onset · Location · Duration · Exacerbating factors · Relieving factors · Prodrome/aura · Associated symptoms · Jaw symptoms · Neck symptoms · Visual deficits/changes · Dizziness/imbalance · Current medications, abortive dose and frequency per month, prophylactic dose · Prior medication trials · Hydration · Meals · Caffeine · Sleep · Exercise · Nicotine/stimulant use · Other comorbid conditions that may contribute to or exacerbate headaches · Risk factors for MOH · History of trauma to the head and/or neck |
Red flags SNOOP(4)E · Systemic symptoms, illness, or condition (e.g., fever, chills, myalgias, night sweats, weight loss or gain, cancer, infection, giant cell arteritis, pregnancy or postpartum, or an immunocompromised state – including HIV) · Neurologic symptoms or abnormal signs (e.g., confusion, impaired alertness or consciousness, changes in behavior or personality, diplopia, pulsatile tinnitus, focal neurologic symptoms or signs, meningismus, or seizures ptosis, proptosis, pain with eye movements) · Onset (e.g., abrupt or "thunderclap" where pain reaches maximal intensity immediately or within minutes after onset; first ever, severe, or "worst headache of life") · Older onset (age ≥50-years) · Progression or change pattern (e.g., in attack frequency, severity, or clinical features) · Precipitated by Valsalva (e.g., coughing or bearing down) · Postural aggravation · Papilledema · Exertion |
Examination · Cranial nerves (including funduscopic exam) · Cervical spine and surrounding musculature (palpation, ROM, Spurling’s) · Temporomandibular joint (palpation, ROM, symmetry, jaw claudication) · Pericranial muscle palpation · General neurologic (upper extremities reflexes, sensation, strength, UMN, pathologic reflexes) · Temporal artery palpation (tenderness, cord-like artery, or lack of pulse) · Blood pressure Standardized headache assessments: · MIDAS · HIT-6 · MSQL |
Sidebar 2: Criteria for Determining Primary Versus Secondary Headache Disorders
Initial evaluation of headache should be targeted at determining if there is a secondary cause for the headache or if the diagnosis of a primary headache disorder is appropriate. Emergent evaluation should be considered based on red flag features. In general, a secondary headache can be diagnosed if the headache is new and occurs in close temporal relation to another disorder that is known to cause headache. It can also be diagnosed when a pre- existing headache disorder significantly worsens in close temporal relation to a causative disorder in which case both the primary and secondary headache diagnoses should be given. ICHD-3 diagnostic criteria are below.
General diagnostic criteria for secondary headaches:
The secondary headaches include: headache attributed to trauma or injury to the head and/or neck, cranial or cervical vascular disorder, non-vascular intracranial disorder, a substance or its withdrawal, infection, disorder of homeostasis, disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, other facial or cervical structure, or psychiatric disorder
General diagnostic criteria for secondary headaches:
- Any headache fulfilling C
- Another disorder scientifically documented to be able to cause headache has been diagnosed. Evidence of causation demonstrated by at least two of the following:
- Headache has developed in temporal relation to the onset of the presumed causative disorder
- Either or both of the following: headache has significantly worsened in parallel with worsening of the presumed causative disorder or headache has significantly improved in parallel with improvement of the presumed causative disorder
- Headache has characteristics typical for the causative disorder
- Other evidence exists of causation
- Not better accounted for by another ICHD-3 diagnosis
The secondary headaches include: headache attributed to trauma or injury to the head and/or neck, cranial or cervical vascular disorder, non-vascular intracranial disorder, a substance or its withdrawal, infection, disorder of homeostasis, disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, other facial or cervical structure, or psychiatric disorder
Sidebar 3: Primary Headache Disorders Criteria
| Tension-type headachea | Migraine headacheb | Cluster headachec | ||
| Attack duration and frequency | Duration | 30-minutes – 7-days | 4 – 72 hours | 15 – 180 minutes |
| Frequency | Variable | Variable | Once every other day to eight per day; often occurring at the same time of day | |
| Headache characteristics | Severity | Mild to moderate | Moderate to severe | Severe or very severe |
| Location | Bilateral | Unilateral | Unilateral orbital, supraorbital, and/or temporal | |
| Quality | Pressing or tightening, non-pulsating | Throbbing or pulsating | Stabbing, boring | |
| Aggravated by routine physical activity | Not aggravated by routine activity | Aggravated by routine activity | Causes a sense of agitation or restlessness; routine activity may improve symptoms | |
| Associated features | Photophobia and phonophobia | Can have one but not both | Both | Variably present |
| Nausea and/or vomiting | Neither | Either or both | May be present | |
| Other features | Autonomic features | None | May occur, but are often subtle and not noticed by the patient | Prominent autonomic features ipsilateral to the pain (see Appendix A in full text Headache CPG) |
a A diagnosis of TTH requires at least 10 headache attacks lasting 30-minutes to 7-days with at least two defining characteristics (i.e., bilateral location, non-pulsating quality, mild to moderate intensity, not aggravated by routine physical activity), and both of the associated features (i.e., no nausea or vomiting; either photophobia or phonophobia, but not both). If headaches fulfill all but one of the TTH criteria (e.g., having both photophobia and phonophobia), the diagnosis would be probable TTH.
b A diagnosis of migraine requires at least five attacks lasting 4 – 72 hours with at least two defining headache characteristics (i.e., unilateral, throbbing/pulsating, moderate or severe intensity, aggravated, or caused by routine physical activity) and at least one associated feature (i.e., nausea and/or vomiting and both photophobia and phonophobia). If headaches fulfill all but one of the migraine criteria (e.g., photophobia or phonophobia but not but photophobia and phonophobia), the diagnosis would be probable migraine.
c A diagnosis of cluster headache requires at least five attacks of severe to very severe unilateral orbital, supraorbital, and/or temporal pain lasting 15 – 180 minutes and occurring once every other day to no more than eight times a day. Either or both autonomic features and a feeling of restless/agitation are required.
* There are definitions for probable TTH, probable migraine, or probable cluster headache where patients may not fulfill all criteria listed above. The Work Group suggests that providers should not withhold therapy when patients do not meet all criteria listed for TTH, migraine, or cluster headache (i.e., are diagnosed with probable TTH, probable migraine, or probable cluster headache).[7] Providers should continually reassess patients during therapy (see Box 19 in Module A).
b A diagnosis of migraine requires at least five attacks lasting 4 – 72 hours with at least two defining headache characteristics (i.e., unilateral, throbbing/pulsating, moderate or severe intensity, aggravated, or caused by routine physical activity) and at least one associated feature (i.e., nausea and/or vomiting and both photophobia and phonophobia). If headaches fulfill all but one of the migraine criteria (e.g., photophobia or phonophobia but not but photophobia and phonophobia), the diagnosis would be probable migraine.
c A diagnosis of cluster headache requires at least five attacks of severe to very severe unilateral orbital, supraorbital, and/or temporal pain lasting 15 – 180 minutes and occurring once every other day to no more than eight times a day. Either or both autonomic features and a feeling of restless/agitation are required.
* There are definitions for probable TTH, probable migraine, or probable cluster headache where patients may not fulfill all criteria listed above. The Work Group suggests that providers should not withhold therapy when patients do not meet all criteria listed for TTH, migraine, or cluster headache (i.e., are diagnosed with probable TTH, probable migraine, or probable cluster headache).[7] Providers should continually reassess patients during therapy (see Box 19 in Module A).
Sidebar 4: Treatment Options for Tension-type Headache
| Sidebar 4: Treatment Options for Tension-type Headachea, b | ||
| Type | Treatment | Notes |
| Non-pharmacologic Therapy – Preventive | Physical therapy↑ | · “Physical therapy” refers to a range of interventions carried out by licensed physical therapists, including manual therapy, therapeutic exercise, strength and endurance training, self-management training, and adjunctive modalities |
| Pharmacotherapy – Preventive | Amitriptyline↑ | · Accessible for general practitioners to prescribe, inexpensive, and may help with patients who suffer from insomnia. Side effects include dry mouth, dry eyes, weight gain, sedation, dizziness, blurred vision, GI distress, and nausea |
| Botulinum toxin/ neurotoxin↓ | · Evidence suggests intervention is ineffective for preventing chronic TTH | |
| Pharmacotherapy – Abortive | Ibuprofen 400 mg or acetaminophen 1,000 mg↑ | · Evidence suggests a statistically significant between-group difference for acetaminophen 1,000 mg versus placebo, favoring acetaminophen |
a For the full recommendation language, see Recommendations
b Sidebar 8 presents additional treatment options for general headache
Abbreviations: GI: gastrointestinal; mg: milligrams; TTH: tension-type headache
↑ Indicates a “Weak for” recommendation strength; ↓ indicates a “Weak against” recommendation strength
b Sidebar 8 presents additional treatment options for general headache
Abbreviations: GI: gastrointestinal; mg: milligrams; TTH: tension-type headache
↑ Indicates a “Weak for” recommendation strength; ↓ indicates a “Weak against” recommendation strength
Sidebar 5: Common Medications and their Association with MOH
| Sidebar 5: Common Medications and their Association with MOH | |
| MOH Type | Medication Overuse Frequency |
| Acetaminophen overuse | ≥15-days/month for >3-months |
| NSAID overuse | |
| Other non-opioid analgesic overuse | |
| Triptan overuse | ≥10-days/month for >3-months |
| Ergotamine overuse | |
| Opioid overuse | ≥10-days/month for >3-months |
| Combination-analgesic overuse | |
Abbreviations: MOH: medication overuse headache; NSAID: nonsteroidal anti-inflammatory drug
Sidebar 6: Treatment Options for Migraine Headache
| Type | Treatment | Notes |
| Pharmacotherapy – Preventive | AbobotulinumtoxinA and onabotulinumtoxinA↓ | · Not FDA approved or effective for prevention of episodic migraine |
| Candesartan or telmisartan↑↑ | · Applies to episodic and chronic migraine | |
| Combination pharmacotherapy↔ | · Evidence was very low quality for the use of combinations of more than one pharmacotherapeutic agent for prevention of migraine | |
| Erenumab, fremanezumab, or galcanezumab↑ | · Applies to episodic and chronic migraine · FDA approved and effective for prevention of migraine |
|
| Gabapentin↔ | · Applies to episodic migraine · Not FDA approved or effective for prevention of migraine |
|
| Lisinopril↑ | · Applies to episodic migraine only | |
| Magnesium, oral↑ | · Oral magnesium formulations varied in the evidence, including magnesium sulfate, magnesium 2-propyl valerate, and magnesium oxide | |
| Nimodipine or nifedipine↔ | · Applies to episodic migraine only | |
| Nutraceuticals: CoQ10, feverfew, melatonin, omega-3, vitamin B2, vitamin B6↔ |
· Evidence suggests small but somewhat inconsistent benefits in reducing migraine frequency, which slightly outweighed potential harms, such as dose variability in supplements, and some specific harms, such as post- feverfew syndrome or vitamin B6 neurotoxicity in high, sustained doses | |
| OnabotulinumtoxinA↑ | · Applies to chronic migraine only · FDA approved and effective for prevention of chronic migraine |
|
| Propranolol↑ | · FDA approved for prevention of migraine | |
| Topiramate↑ | · Applies to episodic migraine only · FDA approved and effective for prevention of migraine |
|
| Valproate↔ | · Applies to episodic and chronic migraine · FDA approved and effective for prevention of migraine |
|
| Pharmacotherapy – Abortive | Frovatriptan or rizatriptan↑ | · FDA approved and effective for treatment of migraine |
| GON block↑ | · Evidence suggests improvement of pain intensity | |
| Ibuprofen, naproxen, aspirin, or acetaminophen↑ | · FDA approved and effective for treatment of migraine | |
| IV magnesium↑ | · Evidence suggests pain reduction with minimal risks | |
| Sumatriptan, sumatriptan/naproxen, or zolmitriptan↑↑ | · Sumatriptan alone and in combination with naproxen are FDA approved and effective for prevention of migraine · Zolmitriptan is FDA approved and effective for treatment of migraine |
|
| Triptans↑ | · Triptans alone and in combination with naproxen are FDA approved and effective for treatment of migraine |
a For the full recommendation language, see Recommendations
bSidebar 8 presents additional treatment options for general headache
Abbreviations: CoQ10: coenzyme Q10; FDA: U.S. Food and Drug Administration; GON: greater occipital nerve block; IV: intravenous
↑↑ Indicates a “Strong for” recommendation strength; ↑ indicates a “Weak for” recommendation strength; ↓ indicates a “Weak against” recommendation strength; ↔ indicates a “Neither for nor against” recommendation strength
bSidebar 8 presents additional treatment options for general headache
Abbreviations: CoQ10: coenzyme Q10; FDA: U.S. Food and Drug Administration; GON: greater occipital nerve block; IV: intravenous
↑↑ Indicates a “Strong for” recommendation strength; ↑ indicates a “Weak for” recommendation strength; ↓ indicates a “Weak against” recommendation strength; ↔ indicates a “Neither for nor against” recommendation strength
Sidebar 7: Treatment Options for Cluster Headache
| Sidebar 7: Treatment Options for Cluster Headachea, b | ||
| Type | Treatment | Notes |
| Non-pharmacologic Therapy – Abortive | Non-invasive vagus nerve stimulation↑ | · For episodic cluster headache only |
| Pharmacotherapy – Prevention | Galcanezumab↑ | · FDA approved and effective for episodic cluster headache only |
| Lovastatin# | · For episodic and chronic cluster headache | |
| Pravastatin# | · For episodic and chronic cluster headache | |
| Pharmacotherapy – Abortive | Oxygen therapy↔ | · For episodic cluster headache only |
| Pharmacotherapy for acute treatment↔ | · Evidence is limited for specific pharmacotherapy for acute treatment of cluster headache | |
| Sumatriptan SQ (not oral)# | · For episodic and chronic cluster headache | |
| Zolmitriptan nasal spray# | · FDA approved and effective for episodic and chronic cluster headache | |
a For the full recommendation language, see Recommendations
b Sidebar 8 presents additional treatment options for general headache
Abbreviations: FDA: U.S. Food and Drug Administration; SQ: subcutaneous
↑ Indicates a “Weak for” recommendation strength; ↔ indicates a “Neither for nor against” recommendation strength; # indicates the treatment was “Not reviewed” in the CPG’s evidence review
b Sidebar 8 presents additional treatment options for general headache
Abbreviations: FDA: U.S. Food and Drug Administration; SQ: subcutaneous
↑ Indicates a “Weak for” recommendation strength; ↔ indicates a “Neither for nor against” recommendation strength; # indicates the treatment was “Not reviewed” in the CPG’s evidence review
Sidebar 8: Treatment Options for Headache in General
| Type | Treatment | Notes |
| Non-pharmacologic Therapy | Acupuncture↔ | · Evidence suggests small or inconsistent benefits for migraine and TTH in comparison to sham acupuncture · No statistically significant differences when compared to beta-blockers, valproic acid, or CCBs, which are also reviewed in this CPG |
| Aerobic exercise/ progressive strength training↑ | · Evidence suggests aerobic exercise and progressive strength training decreases headache frequency | |
| CBT or biofeedback↔ | · Although CBT and biofeedback are commonly used, there was insufficient evidence in this CPG’s systematic evidence review to support a recommendation | |
| Dietary trigger education↑ | · While the evidence regarding dietary trigger avoidance is limited, it is reasonable to offer patient education regarding diet modification to decrease the frequency and/or severity of their migraine headache | |
| Dry needling↔ | · Evidence of dry needling compared to no treatment was limited | |
| Elimination-based diet testing↔ | · There was insufficient evidence in this CPG’s systematic evidence review to support a recommendation | |
| Mindfulness-based therapy↑ | · Improved outcomes of headache frequency and other potential benefits outweigh the harms with this relatively low-risk activity | |
| Neuromodulation↔ | · There was insufficient evidence in this CPG’s systematic evidence review to support a recommendation · Some patients experienced headache following treatment |
|
| Pulsed radiofrequency or SPG↔ | · There was insufficient evidence in this CPG’s systematic evidence review to support a recommendation · Feasibility and acceptability limit these interventions |
|
| Pharmacotherapy – Preventive | Fluoxetine or venlafaxine↔ | · There was insufficient evidence in this CPG’s systematic evidence review to support a recommendation |
| Pharmacotherapy – Abortive | IV ketamine↓ | · Further research should be conducted before administering to patients with headache |
| IV metoclopramide, IV prochlorperazine, or intranasal lidocaine↔ | · There was insufficient evidence in this CPG’s systematic evidence review to support a recommendation |
a For the full recommendation language, see Recommendations
Abbreviations: CBT: cognitive behavioral therapy; CCB: calcium channel blockers; CPG: Clinical Practice Guideline; IV: intravenous; SPG: sphenopalatine ganglion; TTH: tension-type headache
↑ Indicates a “Weak for” recommendation strength; ↓ indicates a “Weak against” recommendation strength; ↔ indicates a “Neither for nor against” recommendation strength
Abbreviations: CBT: cognitive behavioral therapy; CCB: calcium channel blockers; CPG: Clinical Practice Guideline; IV: intravenous; SPG: sphenopalatine ganglion; TTH: tension-type headache
↑ Indicates a “Weak for” recommendation strength; ↓ indicates a “Weak against” recommendation strength; ↔ indicates a “Neither for nor against” recommendation strength
Table 1. Prevention Dosing Information
| Type | Drug | Initial Dose | Usual Range | Comments | ||||
| Beta-adrenic antagonists | Atenolol (Tenormin®) | 50 mg/day | 50 – 200 mg/day | · Dose should be titrated and maintained for at least three months before assessment of response | ||||
| Metoprolol (Toprol®, Toprol XL®) | 100 mg/day in divided doses | 100 – 200 mg/day in divided doses | · Dose short-acting four times a day and long-acting two times a day · Available as extended release · Dose should be titrated and maintained for at least three months before assessment of response |
|||||
| Nadolol (Corgard®) | 40 – 80 mg/day | 80 – 240 mg/day | · Dose should be titrated and maintained for at least three months before assessment of response | |||||
| Propranolol (Inderal®, Inderal® LA) | 40 mg/day in divided doses | 40 – 160 mg/day in divided doses | · Dose short-acting 2 – 3 times a day and long-acting 1 – 2 times a day · Available as extended release · Dose should be titrated and maintained for at least three months before assessment of response |
|||||
| Timolol (Blocadren®) | 20 mg/day in divided doses | 20 – 60 mg/day in divided doses | · Dose should be titrated and maintained for at least three months before assessment of response | |||||
| Antidepressants | Amitriptyline (Elavil™) | 10 mg at bedtime | 20 – 50 mg at bedtime | · Use slow titration to reduce sedation | ||||
| Venlafaxine (Effexor®, Effexor- XR®) | 37.5 mg/day | 75 – 150 mg/day | · Available as extended release · Increase dose after one week |
|||||
| Anticonvulsants | Topiramate (Topamax®) | 25 mg/day | 50 – 200 mg/day in divided doses | · As effective as amitriptyline, propranolol, or valproate · Increase by 25 mg/week |
||||
| Valproic acid/ divalproex sodium (Depakene®, Depakote®, Depakote ER®) | 250 – 500 mg/ day in divided doses, or daily for extended release | 500 – 1,500 mg/day in divided doses, or daily for extended release | · Monitor levels if compliance is an issue | |||||
| Calcitonin Gene-related Peptide Inhibitors | Eptinezumab-jjmr (Vyepti™) | 100 mg IV every 3 months | up to 300 mg IV every 3 months | · May contain polysorbate 80 (also known as Tweens), which can cause hypersensitivity reactions | ||||
| Erenumab-aooe (Aimovig®) | 70 mg SQ monthly | 70 – 140 mg SQ monthly | · May cause constipation, packaging may contain latex | |||||
| Fremanezumab- vfrm (Ajovy®) | 225 mg SQ monthly | 225 mg SQ monthly or 675 mg SQ every 3 months |
· May contain polysorbate 80 (also known as Tweens), which can cause hypersensitivity reactions | |||||
| Galcanezumab- gnlm (Emgality®) | 120 mg SQ monthly (migraine), 300 mg SQ (cluster) | Can use 240 mg loading dose for migraine, use in cluster should continue monthly until end of cluster period | · May contain polysorbate 80 (also known as Tweens), which can cause hypersensitivity reactions | |||||
| Nonsteroidal Anti-inflammatory Drugs | Ibuprofen (Motrin®) | 400 – 1,200 mg/ day in divided doses |
Same as initial dose | · Use intermittently, such as for menstrual migraine prevention; daily or prolonged use may lead to medication overuse headache and is limited by potential toxicity | ||||
| Ketoprofen (Orudis®) | 150 mg/day in divided doses | Same as initial dose | · Use intermittently, such as for menstrual migraine prevention; daily or prolonged use may lead to medication overuse headache and is limited by potential toxicity | |||||
| Naproxen sodium (Aleve®, Anaprox®) | 550 – 1,100 mg/ day in divided doses |
Same as initial dose | · Use intermittently, such as for menstrual migraine prevention; daily or prolonged use may lead to medication overuse headache and is limited by potential toxicity | |||||
| Triptans | Frovatriptan (Frova®) | 2.5 mg/day or 5 mg/day in divided doses |
Same as initial dose | · Taken in the perimenstrual period to prevent menstrual migraine | ||||
| Naratriptan (Amerge®) | 2 mg/day in divided doses | Same as initial dose | · Taken in the perimenstrual period to prevent menstrual migraine | |||||
| Zolmitriptan (Zomig®) | 5 – 7.5 mg/day in divided doses | Same as initial dose | · Taken in the perimenstrual period to prevent menstrual migraine | |||||
| Miscellaneous | Histamine (Histatrol®) | 1 – 10 mg two times/week | Same as initial dose | · May cause transient itching and burning at injection site | ||||
| Magnesium | 400 mg/day | 800 mg/day in divided doses | · May be more helpful in migraine with aura and menstrual migraine | |||||
| MIG-99 (feverfew) | 10 – 100 mg/day in divided doses | Same as initial dose | · Withdrawal may be associated with increased headaches | |||||
| Petasites | 100 – 150 mg/ day in divided doses | 150 mg/day in divided doses | · Use only commercial preparations, plant is carcinogenic | |||||
| Riboflavin | 400 mg/day in divided doses | 400 mg/day in divided doses | · Benefit only after 3 months | |||||
Abbreviations: ER: extended release; LA: long acting; mg: milligrams; SQ: subcutaneously; XL: extended release; XR: extended release
Table 2. Abortive Dosing Information
| Type | Drug | Dose | Comments | ||||||
| Analgesics | Acetaminophen (Tylenol®) | 1,000 mg at onset; repeat every 4 – 6 hours as needed | · Maximum daily dose is 4 g | ||||||
| Acetaminophen 250 mg/aspirin 250 mg/caffeine 65 mg (Excedrin® Migraine) | 2 tablets at onset and every 6-hours | · Available OTC as Excedrin® Migraine | |||||||
| Nonsteroidal Anti- inflammatory Drugs | Aspirin | 500 – 1,000 mg every 4 – 6 hours | · Maximum daily dose is 4 g | ||||||
| Diclofenac (Cataflam®, Voltaren®) | 50 – 100 mg at onset; can repeat 50 mg in 8-hours | · Avoid doses >150 mg/day | |||||||
| Ibuprofen (Motrin®) | 200 – 800 mg every 6-hours | · Avoid doses >2.4 g/day | |||||||
| Naproxen sodium (Aleve®, Anaprox®) | 550 – 825 mg at onset; can repeat 220 mg in 3 – 4 hours | · Avoid doses >1.375 g/day | |||||||
| Ergotamine Tartrate | Oral tablet (1 mg) with caffeine 100 mg (Cafergot®) | 2 mg at onset; then 1 – 2 mg every 30-minutes as needed | · Maximum dose is 6 mg/day or 10 mg/ week · Consider pretreatment with an antiemetic |
||||||
| Sublingual tablet (2 mg) (Ergomar®) | 2 mg SL at the first sign of an attack. Then, 2 mg SL after 30 minutes if needed. If the additional dose is well tolerated, the initial dose may be increased at the next attack, up to a maximum initial dose of 4 mg ergotamine. | · Do not exceed 3 tablets (6 mg ergotamine)/24-hours per any 1 attack | |||||||
| Rectal suppository (2 mg) with caffeine 100 mg (Cafergot®, Migergot®) | Insert 1/2 to 1 suppository at onset; repeat after 1-hour as needed | · Maximum dose is 4 mg/day or 10 mg/ week · Consider pretreatment with an antiemetic |
|||||||
| Dihydroergotamine | Injection 1 mg/mL (D.H.E. 45®) | 0.25 – 1 mg at onset IM, IV, or subcutaneous; repeat every hour as needed | · Maximum dose is 3 mg/day or 6 mg/ week | ||||||
| Nasal spray 4 mg/mL (Migranal®) | One spray (0.5 mg) in each nostril at onset; repeat sequence 15-minutes later (total dose is 2 mg or four sprays) |
· Maximum dose is 3 mg/day · Prime sprayer four times before using · Do not tilt head back or inhale through nose while spraying · Discard open ampules after 8-hours |
|||||||
| Triptans | Zolmitriptan (Zomig®) | 5 – 7.5 mg/day in divided doses Same as initial dose | · Taken in the perimenstrual period to prevent menstrual migraine | ||||||
| Almotriptan (Axert®) | 6.25 or 12.5 mg at onset; can repeat after 2-hours if needed | · Optimal dose is 12.5 mg · Maximum daily dose is 25 mg |
|||||||
| Eletriptan (Relpax®) | 20 or 40 mg at onset; can repeat after 2-hours if needed | · Maximum single dose is 40 mg · Maximum daily dose is 80 mg |
|||||||
| Frovatriptan (Frova®) | 2.5 or 5 mg at onset; can repeat in 2-hours if needed | · Optimal dose 2.5 – 5 mg · Maximum daily dose is 7.5 mg (three tablets) |
|||||||
| Sumatriptan (Imitrex®) injection | 6 mg subcutaneous at onset; can repeat after 1-hour if needed | · Maximum daily dose is 12 mg | |||||||
| Naratriptan (Amerge®) | 1 or 2.5 mg at onset; can repeat after 4-hours if needed | · Optimal dose is 2.5 mg · Maximum daily dose is 5 mg |
|||||||
| Zolmitriptan nasal spray | 5 mg (one spray) at onset; can repeat after 2-hours if needed | · Maximum daily dose is 10 mg/day | |||||||
| Sumatriptan nasal spray | 5, 10, or 20 mg at onset; can repeat after 2-hours if needed | · Optimal dose is 20 mg · Maximum daily dose is 40 mg · Single-dose device delivering 5 or 20 mg · Administer one spray in one nostril |
|||||||
| Zolmitriptan oral tablets | 2.5 or 5 mg at onset as regular or orally disintegrating tablet; can repeat after 2-hours if needed | · Optimal dose is 2.5 mg · Maximum dose is 10 mg/day |
|||||||
| Sumatriptan oral tablets | 25, 50, 85, or 100 mg at onset; can repeat after 2-hours if needed | · Optimal dose is 50 – 100 mg · Maximum daily dose is 200 mg · Combination product with naproxen, 85 mg/500 mg |
|||||||
| Rizatriptan (Maxalt®, Maxalt-MLT®) | 5 or 10 mg at onset as regular or orally disintegrating tablet; can repeat after 2-hours if needed | · Optimal dose is 10 mg · Maximum daily dose is 30 mg · Onset of effect is similar with standard and orally disintegrating tablets · Use 5 mg dose (15 mg/day maximum) in patients receiving propranolol |
|||||||
| Calcitonin Gene Related Peptides Inhibitors | Rimegepant (Nurtec™) | 75 mg orally disintegrating tablet | · 75 mg per day, doses should not be more frequent than >48-hours · Avoid strong CYP3A4 inhibitors, strong or moderate CYP3A4 inducers, p-glycoprotein inhibitors |
||||||
| Ubrogepant (Ubrelvy®) | 50 – 100 mg as a single dose, may repeat in >2-hours | · Up to 200 mg/24-hours, contraindicated with CYP3A4 inhibitors, dose adjustment in moderate renal impairment and severe (Child Pugh Class C) hepatic impairment | |||||||
| Selective Serotonin 1F Receptor Agonist | Lasmidtan (Reyvow™) | 50 mg, maximum of one dose per 24-hours | · 50 – 200 mg per 24-hours as a single dose · Is a Schedule V drug, may not drive for 8-hours after dose |
||||||
| Miscellaneous | Metoclopramide (Reglan®) | 10 mg IV at onset | · Useful for acute relief in the office or ED setting | ||||||
| Prochlorperazine (Compazine®) | 10 mg IV or IM at onset | · Useful for acute relief in the office or ED setting | |||||||
Abbreviations: CYP3A4: cytochrome P450 3A4; D.H.E.: dihydroergotamine; ED: emergency department; IM: intramuscular; IV: intravenous; mg: milligrams; mL: milliliters; OTC: over-the-counter
Recommendation Grading
Disclaimer
Overview
Title
Primary Care Management of Headache
Authoring Organization
Publication Month/Year
July 1, 2020
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Male, 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