Headache treatment in adults

Patient information: Headache treatment in adults

Authors
Zahid H Bajwa, MD
R Joshua Wootton, MDiv, PhD
Section Editor
Jerry W Swanson, MD
Deputy Editor
John F Dashe, MD, PhD

Disclosures

HEADACHE OVERVIEW — In many people, headaches can be well controlled with a combination of medicines and complementary therapies. Treatment is most successful when it is tailored to your needs.

The treatment of tension, chronic daily, medication overuse, and cluster headaches will be reviewed here (table 1). Migraine headaches are discussed separately. (See “Patient information: Migraine headaches in adults”.)

The causes and diagnosis of headache are discussed separately. (See “Patient information: Headache causes and diagnosis in adults”.) A discussion of headaches in children is also available. (See “Patient information: Headache in children”.)

HEADACHE TREATMENT TYPES — Headache treatment depends upon the frequency, severity, and symptoms of your headache.

Acute treatment refers to medicines you can take when you have a headache to relieve the pain immediately.
Preventive treatment refers to medicines you can take on a regular (usually daily) basis to prevent headaches in the future.
TENSION TYPE HEADACHE TREATMENT

Acute treatment — Tension type headaches that occur less than 15 times per month can usually be treated with a pain reliever. (See “Tension-type headache in adults: Acute treatment”.)

Pain reliever — A pain reliever may be recommended first for the treatment of tension type headache. These drugs include:

Aspirin
Acetaminophen (eg, Tylenol®)
Nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen (eg, Motrin or Advil), indomethacin, or naproxen (eg, Naprosyn or Aleve).
Pain relievers should not be used too often because overuse can lead to medication-overuse headaches or chronic daily headaches. If you respond to a pain reliever, you should continue taking these with each headache. However:

Do not use pain relievers more than nine days per month on average, or more than two doses per episode.
If a pain reliever does not control your headache, talk to your healthcare provider for other suggestions.
People with gastritis (inflammation of the stomach), ulcers, kidney disease, and bleeding conditions should not take products containing aspirin or NSAIDs.

Pain medicine combinations — Mild pain relievers are also available in combination with caffeine, which enhances the drug’s effect. As an example, Excedrin® contains a combination of acetaminophen-aspirin-caffeine. This combination may be recommended if a pain reliever alone does not relieve the headache. However, this combination is not recommended more than nine days per month due to the potential risk of developing medication-overuse headaches.

Combination medicines containing butalbital and opioids — A small percentage of people with headaches do not respond to routine treatments and may require additional, prescription medicines for pain. Combinations of an opioid (narcotic) and a pain reliever are available, but are generally not recommended since they are habit-forming and can increase the risk of medication-overuse headaches and chronic daily headaches. Even so, such medications may be considered in special situations where simple pain relievers are ineffective or contraindicated (eg, women in the third trimester of pregnancy, patients with ulcers, severe kidney failure, or liver failure). When healthcare providers encounter patients who are using opioids and barbiturates inappropriately, a “stop or brake” policy may be put into place. The use of these medications is then either stopped, or the frequency of use is braked by limiting them to no more than two days per week and 18 tablets per month.

Preventive treatment — Preventive therapy is recommended for people with headaches more than two to three times per week. (See “Tension-type headache in adults: Preventive treatment”.)

Antidepressants — Antidepressant medicines called tricyclics (TCAs) are often used to help prevent frequent tension headaches. Examples of TCAs include amitriptyline (used most commonly), nortriptyline, and protriptyline.

The dose of TCAs used for people with headaches is typically much lower than that used for treating depression. It is believed that these drugs reduce pain perception when used in low doses, although it is not exactly clear how the medicines work.

It is common to feel tired when you start taking TCAs; this is not always an undesirable side effect since it can help improve sleep if you take TCAs in the evening. TCAs are generally started in low doses and increased gradually. Their full effect may not be seen for weeks to months.

Other treatments — Tricyclic antidepressants are sometimes used in combination with behavioral therapy to prevent tension-type headaches. The goal of behavioral therapy is to identify and try to avoid behaviors that can trigger a headache. (See ‘Lifestyle changes’ below.)

CHRONIC DAILY HEADACHE TREATMENT — The management of chronic daily headache depends on the type of background headache (eg, chronic migraine or chronic tension-type headache) and the presence or absence of medication overuse. (See “Overview of chronic daily headache”, section on ‘Treatment’.)

The treatment of chronic migraine should focus on preventive therapy while avoiding migraine triggers and limiting the use of acute headache medications to avoid medication overuse headache. Preventive treatments include medicines, behavioral therapy, or physical therapy. Management often requires the simultaneous use of these different treatments. (See “Chronic migraine”, section on ‘Management’.)
For chronic tension-type headache, effective treatment involves the use of daily preventive medications (eg, tricyclic antidepressants), behavioral therapies and physical therapy. Like chronic migraine, the combined use of these interventions is often best. (See “Tension-type headache in adults: Preventive treatment” and “Tension-type headache in children”, section on ‘Treatment’.)
For medication overuse headache, basic steps are patient education, withdrawal of the overused medication, bridge therapy aimed at headache relief during medication withdrawal, establishment of a headache treatment program appropriate for the underlying type of headache, and relapse prevention. (See “Medication overuse headache: Treatment and prognosis”.)
CLUSTER HEADACHE TREATMENT — Most people who suffer with cluster headaches will need both acute and preventive medicines. (See “Cluster headache: Acute and preventive treatment”.)

Acute therapy — Acute therapy often includes one or more of the following:

Inhaling 100 percent oxygen through a face mask for 20 minutes. Oxygen treatment is often recommended first because it has few side effects.
Triptans are medicines often used to treat migraines. Triptans (especially injections of sumatriptan) can stop a cluster headache, often within 20 to 30 minutes. If you are unable to give yourself an injection, options include inhaled (nasal spray) sumatriptan or zolmitriptan.
If neither oxygen nor triptans are helpful, alternative choices include octreotide (an injection), lidocaine (liquid applied inside the nose), and ergotamine (a tablet dissolved under the tongue).

Preventive treatment — Preventive therapy is usually started as soon as possible and taken every day when a new cluster of headaches develops. Some people require a combination of medicines. Preventive medicines may be gradually stopped after the cluster has passed, but can be restarted if symptoms recur. The best studied medicines include:

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 headache.

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 who 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 (eg, women who are pregnant or breastfeeding). (See “Headache in pregnancy”.)

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.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

 

Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient Level Information:

Patient information: Migraine headaches in adults
Patient information: Headache causes and diagnosis in adults
Patient information: Headache in children

Professional Level Information:

Acute treatment of migraine in adults
Basilar-type migraine
Chronic migraine
Cluster headache: Acute and preventive treatment
Cluster headache: Epidemiology, clinical features, and diagnosis
Estrogen-associated migraine
Evaluation of headache in adults
Evaluation of the adult with headache in the emergency department
Headache in pregnancy
Headache syndromes other than migraine
Headache, migraine, and stroke
Hypnic headache
Medication overuse headache: Etiology, clinical features, and diagnosis
Overview of chronic daily headache
Pathophysiology, clinical manifestations, and diagnosis of migraine in adults
Post-lumbar puncture headache
Preventive treatment of migraine in adults
Tension-type headache in adults: Acute treatment
Tension-type headache in adults: Pathophysiology, clinical features, and diagnosis
Tension-type headache in adults: Preventive treatment
Thunderclap headache

The following organizations also provide reliable health information.

National Library of Medicine
(www.nlm.nih.gov/medlineplus/headache.html, available in Spanish)

National Institute of Neurological Disorders and Stroke
(www.ninds.nih.gov/disorders/headache/headache.htm)

American Headache Society
(www.achenet.org/resources/information_for_patients/)

REFERENCES
Turk, DC, Winter, F. The Pain Survival Guide: How to Reclaim Your Life. Washington, DC: American Psychological Association, 2005.
Caudill, MA. Managing Pain Before It Manages You, 3rd Edition. New York: Guilford Press, 2009.
Dodick DW. Clinical practice. Chronic daily headache. N Engl J Med 2006; 354:158.
Lipton RB, Stewart WF, Stone AM, et al. Stratified care vs step care strategies for migraine: the Disability in Strategies of Care (DISC) Study: A randomized trial. JAMA 2000; 284:2599.
Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2000; 55:754.
Silberstein, SD, Rosenberg, J. Multispecialty consensus on diagnosis and treatment of headache. Neurology 2000; 54:1553. Full text of guidelines available at www.neurology.org/cgi/reprint/54/8/1553?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=1&title=headache+consensus&andorexacttitle=and&andorexacttitleabs=and&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT.
Mathew NT. Transformed migraine, analgesic rebound, and other chronic daily headaches. Neurol Clin 1997; 15:167.
Silberstein SD, Goadsby PJ. Migraine: preventive treatment. Cephalalgia 2002; 22:491.
Tomkins GE, Jackson JL, O’Malley PG, et al. Treatment of chronic headache with antidepressants: a meta-analysis. Am J Med 2001; 111:54.