Skip to content

Outpatient Headache

Lauren Waskowicz

Type Presentation First line meds
Tension type (most common) Generally bilateral, pressure/tightness, mild/moderate pain, no significant photophobia, phonophobia, or nausea Acetaminophen, TCAs, SNRIs
Migraine

Unilateral, pulsating, moderate-to-severe pain, lasts 4-72hr, worse with activity and improves with sleep

Associated with nausea, photophobia or phonophobia

± Aura

Acute: triptans

Preventive: TCAs, propranolol, topiramate, VPA
Cluster Severe, often extreme unilateral orbital/supra-orbital/temporal pain, often with lacrimation, rhinorrhea, sweating, swelling of face, visual changes Acute: 100% FiO2 at 12L/min for at least 15 mins, triptans, Indomethacin
Medication Overuse HA at least ½ the days of the month, w/medication intake at least ½ the days of the month; often presents as worsening HA despite increased intake of medication. Often seen with meds that include caffeine (Excedrin, fioricet) \*STOP offending medication, typically via taper. HA will worsen before it gets better, start concurrent daily prophylactic headache medication

Evaluation:

  • Assess for red flag symptoms (refer to “Headache: Inpt”)

  • If no red flag symptoms present, no need for further work-up

  • Assess lifestyle factors that can be contributing to headache: good sleep hygiene, routine meal schedules, regular exercise, and managing migraine triggers

Medication Overview:

  • Abortive

    • Triptans: Cannot be used more than 10 days/month. Avoid in pts with significant coronary artery disease, prior strokes, and prior MI. Associated with vasospasm.
    • CGRP antagonists: Newer options. Insurance typically requires failure of 2 abortive triptans prior to approval. Refer to Neurology Clinic for this.

  • Preventative

    • Amitriptyline: indicated for both migraine and tension-type. Helps with sleep and comorbid depression. Most common side effects (SE) = dry mouth, sedation

    • Topiramate: has the best evidence among migraine meds. Can theoretically help with weight loss. Most common SE = sodas taste bad, sedation, parasthesias

    • Propranolol: useful for relative lack of interactions. Mild cardiac/blood pressure effects compared to other beta-blockers. Most common SE = drowsiness

    • Magnesium oxide: reduces headache frequency with almost no SE. Start 400mg daily, can go up to 800mg BID. Patients can increase dose until they get diarrhea.

    • Riboflavin (vitamin B2): mild effect but effectively has no side effects. 400mg daily.

    • Gabapentin: can be useful if HAs have stabbing/electric quality. Main SE = sedation

    • Venlafaxine: useful for migraines with significant vestibular symptoms (dizziness). SE = hypertension/tachycardia.

    • Verapamil: can be used for migraine and cluster headaches. Can use ER formulation

    • Botox: can be administered every 3 months. Can be very effective, but pts generally will have had to fail multiple medications for insurance to approve refer to neuro resident clinic

    • CGRP receptor modulators (mostly injections) such as Rimegepant are newer options