First-Line Treatment for Recurrent Headaches

Treatment Algorithm Based on Headache Type and Severity

The American College of Physicians recommends using non-steroidal anti-inflammatory drugs (NSAIDs) as first-line treatment for mild to moderate headaches, including aspirin, ibuprofen, naproxen sodium, and diclofenac potassium 1, 2, 3
The combination of acetaminophen plus aspirin plus caffeine is also effective as first-line therapy for mild to moderate headaches 2, 3
Paracetamol (acetaminophen) alone has less efficacy and should only be used in patients who cannot tolerate NSAIDs 1

The American College of Physicians recommends adding a triptan to an NSAID for moderate to severe headaches that don't respond adequately to an NSAID alone (strong recommendation) 4
Triptans, including oral sumatriptan, naratriptan, rizatriptan, and zolmitriptan, have well-documented effectiveness for moderate to severe headaches 1, 2, 3, 4

For headaches with nausea or vomiting, select a non-oral route of administration, such as subcutaneous sumatriptan or DHE nasal spray 1, 2, 3
Add an antiemetic to treat nausea, even if vomiting is not present 2, 3

Triptans are most effective when taken early in an attack, when headache is still mild 1
Do not use triptans during the aura phase of a migraine attack 1

If one triptan is ineffective, others might still provide relief 1
When all other triptans have failed or in patients who rapidly reach peak headache intensity, sumatriptan by subcutaneous injection can be useful 1, 3
For patients experiencing relapse (return of symptoms within 48 hours), repeating triptan treatment or combining with fast-acting NSAIDs may help 1

If all available triptans fail or are contraindicated, alternatives include ditans (lasmiditan) and gepants (ubrogepant, rimegepant) 1