Quick Reference: GUIDELINE FOR PRIMARY CARE

MANAGEMENT OF HEADACHE IN ADULTS

September 2016
Red flags:
Emergent (address immediately) Urgent (address hours to days)
• Thunderclap onset • Temporal arteritis
• Fever and meningismus • Papilloedema (NO focal signs or reduced LOC*)
• Papilloedema (+focal signs or reduced LOC*)• Relevant systemic illness
• Acute glaucoma • Elderly: new headache with cognitive change
Yes Refer and/or investigate

Possible indicators of secondary headache:

• Unexplained focal signs • Aggravation by neck movement; abnormal
• Atypical headaches neck exam. Consider cervicogenic headache.
• Unusual headache precipitants • Jaw symptoms; abnormal jaw exam. Consider
• Onset after age 50 temporomandibular disorder. Migraine
• Acute medication (Table 1)
• Monitor for medication overuse
No • Prophylactic medication (Table 1), if
headache:
Headache with 2 or more of: Migraine Medication overuse: > 3 days/month and acute
• Nausea Assess meds not effective
• Light sensitivity • Ergots, triptans, combination OR
• Interference with activities
Yes analgesics or codeine/other > 8 days/month (risk of overuse)
opioids ≥ 10 days a month OR
Practice points: OR Disability despite acute meds
• Migraine historically under diagnosed • Acetaminophen or NSAIDs ≥ 15
• Consider migraine diagnosis for days a month
recurring “sinus” headache
Manage
• Educate patient
Behavioural management
• Headache diary: record frequency,
No • Consider prophylactic
intensity, triggers and medication
medication
• Adjust lifestyle factors: reduce
Tension-type • Provide an effective acute med
Headache w/o nausea and 2 or caffeine, ensure regular exercise, avoid
Headache for severe attacks with
more of: irregular and/or inadequate sleep or
limitations on frequency of use
• Bilateral headache meals
• Gradual withdrawal if opioid,
• Non‐pulsating pain Yes or combination analgesic with
Stress management: relaxation
• Mild to moderate pain training, CBT*, pacing activity, biofeedback
opioid or barbiturate
• Not worsened by activity • Abrupt (or gradual) withdrawal
if acetaminophen, NSAIDs, or
triptan Tension‐type headache
No • Acute medication (Table 2)
• Monitor for medication overuse
Uncommon headache syndromes • Prophylactic medication if disability
*LOC - loss of consciousness despite acute meds (Table 2)
All of: *CBT - cognitive behavioural therapy
• Frequent headache
• Severe
• Brief < 3 hours per attack Cluster headache or another
• Unilateral (always same side) trigeminal autonomic cephalalgia
• Ipsilateral eye redness, tearing • Management primarily pharmacological
and/or restlessness during attacks
Yes • Acute medication (Table 3)
• Prophylactic medication (Table 3)
• Early specialist referral recommended
All of:
• Unilateral headache (always same side)
• Continuous Hemicrania continua
• Dramatically responsive to Yes • Specialist referral
indomethacin

New daily persistent headache

Headache continuous since onset Yes • Specialist referral

The above recommendations are systematically developed statements to assist practitioner and patient decisions about appropriate health care
for specific clinical circumstances. They should be used as an adjunct to sound clinical decision making.
 Quick Reference: MEDICATIONS RECOMMENDED
FOR HEADACHE MANAGEMENT IN ADULTS
Refer to full guideline for migraine treatment in pregnancy and lactation
Table 1: Migraine
Acute Migraine Medication
st
1 line ibuprofen 400 mg, ASA 1,000 mg, naproxen sodium 550 mg, acetaminophen 1,000 mg, diclofenac 50 mg
nd
2 line Triptans: oral sumatriptan 100 mg, rizatriptan 10 mg, almotriptan 12.5 mg, zolmitriptan 2.5 mg
eletriptan 40 mg, frovatriptan 2.5 mg, naratriptan 2.5 mg
 Subcutaneous sumatriptan 6 mg if vomiting early in the attack. Consider for attacks resistant to oral triptans.
 Oral wafer: rizatriptan 10 mg, zolmitriptan 2.5 mg, if fluid ingestion worsens nausea
 Nasal spray: zolmitriptan 5 mg, sumatriptan 20 mg, if nausea
Antiemetics: domperidone 10 mg, metoclopramide 10 mg, for nausea
rd
3 line 550 mg naproxen sodium in combination with triptan
th
4 line Fixed-dose combination analgesics (with codeine if necessary - not recommended for routine use)
Prophylactic Migraine Starting Dose *Titration: Daily Target Dose / Notes
Medication Dose Increase Therapeutic Range
st
1 line propranolol 20 mg bid 40 mg/week 40-120 mg bid
metoprolol 50 mg bid 50 mg/week 50-100 mg bid Avoid in asthma
nadolol 20-40 mg once daily 20 mg/week 80-160 mg daily
amitriptyline 10 mg hs 10 mg/week 10-100 mg hs Consider if depression, anxiety, insomnia
nortriptyline 10 mg hs 10 mg week 10-100 mg hs or tension-type headache
nd st
2 line topiramate 25 mg once daily 25 mg/week 50 mg bid Consider 1 line if overweight
candesartan 8 mg once daily 8 mg/week 16 mg once daily Few side effects; avoid in pregnancy or
when pregnancy is planned
lisinopril 10 mg once daily 10 mg/week 20 mg once daily More side effects than candesartan;
avoid in pregnancy or when pregnancy is
planned
Other divalproex sodium 250 mg once daily 250 mg/week 750-1,500 mg Avoid in pregnancy or when pregnancy is
daily, divided bid planned
pizotifen 0.5 mg daily 0.5 mg/week 1-2 mg bid Monitor for somnolence and weight gain
OnabotulinumtoxinA 155-195 units No titration 155-195 units For chronic migraine only – headache on
needed every 3 months ≥15 days per month
flunarizine 5-10 mg hs 10 mg hs Avoid in depression
venlafaxine 37.5 mg once daily 37.5 mg/week 150 mg once daily Consider in migraine with depression
and/or anxiety
Over magnesium citrate 300 mg bid 300 mg bid
No titration
the riboflavin 400 mg daily 400 mg daily Efficacy may be limited; few side effects
needed
Counter co-enzyme Q10 100 mg tid 100 mg tid
*Titration: Dosage may be increased every two weeks to avoid side effects
 For most drugs, slowly increase to target dose  If target dose not tolerated, try lower dose
 Therapeutic trial requires several months  If med effective and tolerated, continue for at least six months
 Expected outcome is reduction, not elimination of attacks  If several preventive drugs fail, consider specialist referral

Table 2: Tension-Type Headache Table 3: Cluster Headache (consider early specialist referral)
Acute Medication Acute Medication
 ibuprofen 400 mg  subcutaneous sumatriptan 6 mg
 ASA 1,000 mg  intranasal zolmitriptan 5 mg or sumitriptan 20 mg
 naproxen sodium 550 mg OR
 acetaminophen 1,000 mg 100% oxygen at 12 litres/minute for 15 minutes through non-rebreathing mask
Prophylactic Medication *Prophylactic Medication
st st
1 line amitriptyline 10-100 mg hs 1 line verapamil 240-480 mg per day (higher doses may be required)
nd
OR 2 line lithium 900-1,200 mg per day
nortriptyline 10-100 mg hs Other topiramate 100-200 mg per day
nd
2 line mirtazapine 30 mg hs OR
OR melatonin up to 10 mg hs
venlafaxine 150 mg once daily *Note: If more than two attacks per day, consider transitional therapy while verapamil is
built up (e.g., prednisone 60 mg for five days, then reduced by 10 mg every two days until
discontinued, or occipital nerve blockage with steroids by trained physicians).

Abbreviations: hs – at bedtime; bid – twice a day; tid – three times a day

September 2016
These recommendations are systematically developed statements to assist practitioner and patient decisions about appropriate
health care for specific clinical circumstances. They should be used as an adjunct to sound clinical decision making.
 KEY MESSAGES*
DIAGNOSIS AND IMAGING
 Rule out secondary headache when making a diagnosis of a primary headache disorder.
 Neuroimaging is not indicated in patients with recurrent headache with the clinical features
of migraine, a normal neurological examination, and no red flags.
 Neuroimaging, sinus X-rays, cervical spine X-rays, and EEG are not recommended for the
routine assessment of the patient with headache. History and physical/neurological
examination is usually sufficient to make a diagnosis of migraine or tension-type headache.

DIFFERENTIAL DIAGNOSIS
 Migraine is by far the most common headache type in patients seeking help for headache
from physicians.
 Migraine is historically under-diagnosed and under-treated. Many patients with migraine are
not diagnosed with migraine when they consult a physician.
 Migraine should be considered in patients with recurrent moderate or severe headaches and
a normal neurological examination.
 Patients consulting for bilateral headaches which interfere with their activities are likely to
have migraine rather than tension-type headache and may require migraine specific
medication.
 Consider a diagnosis of migraine in patients with a previous diagnosis of recurring “sinus”
headache.
 Monitor for medication overuse.
 Medication overuse is considered present when patients with migraine or tension-type
headache use combination analgesics, opioids, or triptans on 10 or more days per month or
acetaminophen or NSAIDs on 15 or more days a month.

MANAGING MIGRAINE
 Comprehensive migraine therapy includes management of lifestyle factors and triggers,
acute and prophylactic medications, and migraine self-management strategies.
 ASA, acetaminophen, NSAIDs, and triptans are the primary medications for acute migraine
treatment.
 A triptan should be used when NSAIDs are not effective.
 Opioid-containing analgesics are not recommended for routine use for migraine.
 Butalbital-containing combination analgesics should be avoided.
 Vast amounts of over-the-counter analgesics are taken for headache disorders and
treatment is often sub-optimal.
 A substantial number of people who might benefit from prophylactic therapy do not receive it.
*Refer to Guideline for Primary Care Management of Headache in Adults 2 nd edition, for management
details: www.topalbertadoctors.org/cpgs/10065