Medication Management of Headaches

Treatment of headaches depends greatly upon the frequency, severity, cause and associated symptoms.  Acute treatment is used at the onset of headaches and often include familiar over-the-counter medications such as ibuprofen or aspirin.  Headache treatment can also involve preventative measures to help ward off the recurrence of headaches in those who suffer from frequent occurrences of headaches.

Acute treatment modalities are utilized in all types of headaches.  They are often pain relievers such as aspirin, acetaminophen (e.g., Tylenol®), nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (e.g., Motrin or Advil), indomethacin, or naproxen (e.g., Naprosyn or Aleve).  Most of these can be purchased without a prescription (over-the-counter).  Caution must be exercised when using these medications because using them too frequently can lead to stomach problems, liver and kidney toxicity as well as medication-overuse headaches or rebound headaches.  As a general rule, do not use pain relievers more than nine days per month on average, or more than two doses per episode.  If a pain reliever helps and you are needing it more than what is mentioned above or if it doesn’t control your headache, talk to your healthcare provider.  Many prescription strength medications are available for acute treatment of headaches depending on the type and cause.

Preventative treatment for headaches is recommended for those who suffer from headaches more than two to three times per week.  Types of headaches that often require preventative (prophylactic) therapy include migraines and tension headaches.  Antidepressants and some blood pressure medications are often used to help prevent frequent headaches.  In addition to medical management of these headaches, behavior and physical therapy can be effective adjunctive treatment for prevention.

Oxygen has also been utilized in the medical management of headaches.  Headaches can be treated in offices by inhaling 100 percent oxygen through a face mask for 20 minutes.  Other forms of medical management for headaches include Triptans for migraines or cluster headaches.  These are a special class of prescription drugs that work best if taken within the first hour of a headache.  If first line medical management is not effective, alternative therapies such as octreotide (an injection), lidocaine (liquid applied inside the nose), and ergotamine (a tablet dissolved under the tongue) have been shown to be helpful in special circumstances.

• Verapamil, a calcium channel blocker, is a pill that is effective and has few side effects. The dose may be slowly increased as needed.
• The glucocorticoid drug prednisone (a pill) is an effective preventive therapy. However, long-term use of glucocorticoids is not recommended due to the risk of side effects.

COMPLEMENTARY HEADACHE TREATMENT — Several therapies can be used along with medical treatment in people with headaches.

Lifestyle changes — Some simple lifestyle adjustments can help to reduce the frequency of headaches. These include:

• Stop smoking
• Reduce the amount of alcohol you drink
• Decrease or stop drinking/eating caffeine
• Eat and sleep on a regular schedule
• Exercise several times per week

While there are no clinical trials proving the benefit of these measures, many headache specialists have found them helpful for their patients.

Physical Therapy — Some people with frequent headaches benefit from working with a physical therapist that has a special interest in headaches. This treatment may be used if you do not respond or only partially or temporarily respond to medicines, or if you cannot use medicines (such as women who are pregnant or breastfeeding).

Acupuncture — Acupuncture involves inserting hair-thin, metal needles into the skin at specific points on the body. It causes little to no pain. Electrical stimulation is sometimes applied to the acupuncture needle. Acupuncture has not been proven to improve tension-type or chronic daily headaches. However, people who do not want to try or who cannot tolerate other treatments may try using acupuncture. (See “Tension-type headache in adults: Preventive treatment”, section on ‘Acupuncture’ and “Preventive treatment of migraine in adults”, section on ‘Acupuncture’.)

Behavioral therapy — Headaches can be triggered or worsened by stress, anxiety, depression, and other psychological factors. Furthermore, living with headache pain can cause difficulties in relationships, at work or school, and with general day to day living.

Behavioral therapy works by helping you to address the stress, anger, or frustration that can come with frequent or chronic headache pain. There are many different types of behavioral therapy:

• Psychotherapy involves meeting with a psychologist, psychiatrist, or social worker to discuss emotional responses to living with chronic pain, treatment successes or failures, and/or personal relationships.
• Group psychotherapy allows you to compare your experiences with headaches, overcome the tendency to withdraw and become isolated in your pain, and support others’ attempts with pain management.
• Relaxation techniques can relieve muscle tension, and may include meditation, progressive muscle relaxation, self-hypnosis, and biofeedback. Biofeedback may be especially helpful for people with chronic tension-type headaches.
• Group skill-building exercises help you to learn about living with pain, including ways to improve relationships and build strength, ways to avoid negative thinking, and learning to deal with pain flares. A number of self-help books are also available on these topics, including Turk and Winter’s The Pain Survival Guide: How to Reclaim Your Life, and Caudill’s Managing Pain Before It Manages You [1,2].

Herbal and homeopathic remedies — A number of homeopathic remedies are promoted to relieve or prevent headaches, including migraines. However, the effect of these remedies is not clear and these remedies are not recommended.