Management of Primary Headaches

The management of headache patients depends entirely upon the diagnosis:

Migraine

Analgesics

Analgesics are the first-line treatment for migraine. Aspirin 1000 mg is an effective treatment for acute migraine headaches, similar to sumatriptan 50 mg or 100 mg. [5] Most NSAID’s and paracetamol to be significantly more effective than placebo.

Anti-emetics
Metoclopramide and domperidone relieve the sensation of nausea, overcome gastric stasis and, consequently, enhance the bio-availability of other oral medication.

Non-specific Therapies

Both chlorpromazine (25–50 mg IM) and prochlorperazine (10mg IV or IM) have been used successfully as single agent therapies.

Specific Therapies: Triptans

Many placebo-controlled trials have shown these to be effective in relieving headache at 1 hour. The triptans are most effective if taken when the headache is mild. They are ineffective if taken before the onset of symptoms.

Patients whose migraine does not respond to triptans should be considered for treatment with ergotamine tartrate 1-2 mg.

Tension headaches

In patients with a tension headache, ascertain that the patient is not:

• Over-using analgesic medication
• Showing evidence of drug dependency
• Showing signs of depression

Episodic tension-type headaches generally respond well to over-the-counter analgesics, and in controlled studies, ibuprofen has been found to be more effective than paracetamol.

Other prophylactic medications for chronic tension-type headaches include amitriptyline and sodium valproate.

Regular exercise, stretching, balanced meals, and adequate sleep may be part of a headache treatment program.

Cluster headaches

High flow O₂ therapy i.e. 10 L/minute for 15 minutes is usually effective.

The triptans (e.g. sumatriptan, 6 mg, sub-cut) can also be used.

Exertional headaches

After excluding a structural lesio,n management is aimed at advising the patient of the benign nature of this condition. Some patients benefit from beta-blocker therapy.

Trigeminal neuralgia

A number of drugs have been shown to be effective:

• Carbamazepine
• Phenytoin
• Valproate
• Lamotrigine
• Gabapentin

Approximately 30% of patients do not respond to drug therapy, and these patients may need surgical intervention.