Treatment of Headaches Caused by Psychiatric Medications

Initial Management Approach

The American Academy of Family Physicians recommends starting with standard headache treatments, such as acetaminophen or NSAIDs (ibuprofen, naproxen sodium, or aspirin), if not contraindicated, while simultaneously performing a thorough differential diagnosis to identify other potential causes 1
NSAIDs are the preferred initial therapy for medication-induced headaches, with the strongest evidence supporting aspirin, ibuprofen, naproxen sodium, and the combination of acetaminophen-aspirin-caffeine 2, 3
Acetaminophen alone is ineffective for headache treatment and should not be used as monotherapy 2, 3
Standard analgesics can be used immediately upon headache onset for maximum efficacy 4

Limit acute headache medication use to no more than 2 days per week to minimize rebound risk 6, 7, 5
Simple analgesics (NSAIDs, acetaminophen) should be used fewer than 15 days per month 5
Triptans, if prescribed for severe headaches, must be limited to fewer than 10 days per month 5
Completely avoid medications containing barbiturates, caffeine, butalbital, or opioids, as these carry the highest risk of causing medication-overuse headache 5

The American Academy of Family Physicians recommends starting preventive therapy if the patient experiences two or more headache attacks per month producing disability for 3+ days per month 3, 7
Preventive therapy should also be started if acute medications are being used more than twice per week 7
The American College of Physicians recommends considering preventive therapy if acute treatments have failed or are contraindicated 6

Amitriptyline 30-150 mg/day has the strongest evidence for headache prevention and is particularly beneficial when psychiatric comorbidity exists (depression, anxiety) 8
Beta-blockers (propranolol 80-240 mg/day, timolol 20-30 mg/day) are effective alternatives, particularly for pure migraine without tension features 8

The American College of Physicians recommends establishing a cooperative arrangement for home rescue medication (opioid or butalbital-containing compound) to avoid emergency department visits for severe headaches unresponsive to other treatments 6, 7
Rescue medications permit relief without complete pain elimination or return to normal function 6, 7