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Patient education: Headache treatment in adults (Beyond the Basics)

Patient education: Headache treatment in adults (Beyond the Basics)
Authors:
R Joshua Wootton, MDiv, PhD
Narayan R Kissoon, MD
Section Editor:
Jerry W Swanson, MD, MHPE
Deputy Editor:
Richard P Goddeau, Jr, DO, FAHA
Literature review current through: Nov 2022. | This topic last updated: Apr 29, 2022.

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 headache, chronic daily headache, medication-overuse headache, and cluster headache will be reviewed here (table 1). Migraine headaches are discussed in more detail separately. (See "Patient education: Migraines in adults (Beyond the Basics)".)

The causes and diagnosis of headache are discussed separately. (See "Patient education: Headache causes and diagnosis in adults (Beyond the Basics)".)

A discussion of headaches in children is also available. (See "Patient education: Headache in children (Beyond the Basics)".)

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. You only take these medications as needed when you have severe headache.

Preventive treatment refers to medicines or other treatments you use on a regular (often daily) basis to prevent headaches in the future. You use these treatments as scheduled regardless of whether or not you have a headache at the time.

TENSION-TYPE HEADACHE TREATMENT — Tension-type headaches are very common. They cause pressure or tightness around both sides of the head and neck. People often feel stress or tension before the headache. Unlike migraines, tension-type headaches are usually not associated with other symptoms like nausea, vomiting, or sensitivity to sound or light.

Acute treatment — Tension-type headaches that occur less than 15 times per month can usually be treated with a pain reliever. Headache that occurs on 15 or more days per month is considered "chronic"; the treatment approach for this is different. (See 'Chronic daily headache treatment' below.)

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

Nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen (sample brand names: Motrin, Advil) or naproxen (sample brand names: Aleve, Naprosyn)

Acetaminophen (sample brand name: Tylenol)

Aspirin

Mild pain relievers are also available in combination with caffeine, which enhances the medication's effect; an example is acetaminophen, aspirin, and caffeine (sample brand name: Excedrin). This combination may be recommended if a pain reliever alone does not relieve the headache.

Pain relievers should not be used too often because overuse can lead to medication-overuse headaches or chronic daily headaches. If your headache responds 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 health care 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.

Combination medicines containing butalbital and opioids — Combinations of an opioid 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 cannot be used safely (eg, during the third trimester of pregnancy or comorbid peptic ulcers, severe kidney failure, or liver failure). Health care providers are careful when prescribing these medications in order to minimize the risk of misuse or addiction.

Preventive treatment — Preventive therapy is recommended for people with tension-type headaches that are frequent or long lasting or have a significant impact on a person's ability to do their normal activities.

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. Your health care provider may recommend taking amitriptyline or nortriptyline two hours before bedtime to prevent morning grogginess. If morning grogginess occurs, then the medication could be taken even earlier (around dinnertime). TCAs are generally started in low doses and increased gradually. Their full effect may not be seen for weeks to months.

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 — "Chronic daily headache" means a headache that is present for more than 15 days per month for at least three months. It is not a type of headache but a category that includes different types; most people with chronic daily headache have migraine or tension-type headaches.

The management of chronic daily headache depends on the type of headache and whether medication overuse is a factor.

Chronic migraine – 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, physical therapy, and lifestyle changes (eg, good sleep hygiene, regular exercise, and dietary changes to avoid triggers). Management often requires the simultaneous use of these different treatments.

Chronic tension-type headache – For chronic tension-type headache, effective treatment involves the use of daily preventive medications (eg, tricyclic antidepressants), behavioral therapies, physical therapy, and lifestyle changes (eg, regular exercise and dietary changes). Like chronic migraine, the combined use of these interventions is often best.

Medication-overuse headache – This happens when headaches (of any type) lead to a cycle of taking medication to treat pain, then headache recurring when the medication wears off, then taking more medication. (See "Patient education: Headache causes and diagnosis in adults (Beyond the Basics)", section on 'Medication-overuse headache'.)

The approach to treating medication-overuse headache involves understanding the cycle that is happening, stopping the medication being overused, and working with your health care provider to establish an appropriate headache treatment and prevention plan. Medication-overuse headache can occur even if medication is taken frequently for chronic pain in other parts of the body. The body can become dependent on pain-relieving medications and a headache can develop as a result. This happens because the body is unable to distinguish why the medication is being taken. If you have frequent migraine or tension headaches, you should avoid taking daily pain relieving medications for other types of pain (such as back or joint pain). Your health care provider can talk to you about other treatment options.

CLUSTER HEADACHE TREATMENT — Cluster headaches are severe, debilitating headaches that occur repeatedly for weeks to months at a time, followed by periods with no headache. (See "Patient education: Headache causes and diagnosis in adults (Beyond the Basics)", section on 'Cluster headache'.)

Most people who suffer from cluster headaches will need both acute and preventive medicines.

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

Inhaling 100 percent oxygen through a facemask 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 intranasal lidocaine (liquid applied inside the nose) and ergotamine (a tablet dissolved under the tongue).

Transitional treatment — During a cluster headache cycle, a "transitional" therapy is often used to relieve the headaches while the preventive treatment is adjusted to prevent the return of the headaches:

The glucocorticoid (steroid) drug prednisone is an effective transitional therapy. It is taken as a pill. Long-term use of glucocorticoids is not recommended due to the risk of side effects.

If prednisone is not effective at relieving the headaches or there is a contraindication to using steroids, some providers may suggest a nerve block. This involves injecting pain-relieving medicine around the nerves in the back of the head to help suppress the headaches.

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 type of medication called a calcium channel blocker, comes as a pill and has few side effects. The dose may be slowly increased as needed.

Calcitonin gene-related peptide (CGRP) antibodies are medications that aim to block the transmission of pain. These medications also have few side effects. Galcanezumab is approved for cluster headache treatment and is taken on a monthly basis until one month after the cluster cycle stops.

COMPLEMENTARY TREATMENTS FOR HEADACHE — 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 avoid 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, if you 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.

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, social worker, or other qualified mental health provider 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 (a technique that teaches you to control certain body functions). Biofeedback may be especially helpful for people with chronic tension-type headaches.

Group skill-building exercises help you 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.

Herbal and homeopathic remedies — Several herbal and "homeopathic" remedies are promoted to relieve or prevent headaches, including migraines. Whether and how these remedies work is often unclear. Patients should approach their use carefully and with the supervision of a qualified medical provider.

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

This article will be updated as needed on our web site (www.uptodate.com/patients). 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 — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Headaches in adults (The Basics)
Patient education: Migraines in adults (The Basics)
Patient education: Headaches in children (The Basics)
Patient education: Concussion in adults (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Migraines in adults (Beyond the Basics)
Patient education: Headache causes and diagnosis in adults (Beyond the Basics)
Patient education: Headache in children (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Acute treatment of migraine in adults
Overview of thunderclap headache
Chronic migraine
Cluster headache: Treatment and prognosis
Cluster headache: Epidemiology, clinical features, and diagnosis
Estrogen-associated migraine, including menstrual migraine
Evaluation of headache in adults
Evaluation of the adult with nontraumatic headache in the emergency department
Headache during pregnancy and postpartum
Headache, migraine, and stroke
Medication overuse headache: Etiology, clinical features, and diagnosis
Migraine with brainstem aura
Chronic daily headache: Associated syndromes, evaluation, and management
Pathophysiology, clinical manifestations, and diagnosis of migraine in adults
Post dural puncture headache
Preventive treatment of episodic 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

The following organizations also provide reliable health information.

National Library of Medicine

     (https://medlineplus.gov/headache.html, available in Spanish)

National Institute of Neurological Disorders and Stroke

     (https://www.ninds.nih.gov/Disorders/All-Disorders/Headache-Information-Page)

American Headache Society

     (https://americanheadachesociety.org)

ACKNOWLEDGMENT — The editorial staff at UpToDate would like to acknowledge Zahid H Bajwa, MD, who contributed to an earlier version of this topic review.

This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof. The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2023 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.
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