Headache Treatment – No Absolute Cure

Medically reviewed by Dr. Trudy Cheng. Last updated 28 May 2021 

 

Headache Treatment

While there is no absolute cure for headache, there are a number of helpful treatment options for managing your headache. Depending on what type of headache you have, you can try medication, lifestyle changes, or complementary therapies (such as supplements or meditation). Always consult your medical practitioner before taking any form of treatment.

This article covers the principles of headache management, including:

      1. Understanding and diagnosing your headache;
      2. General approaches towards headache management;
      3. Treatment of migraine;
      4. Treatment of tension-type headache;
      5. Treatment of cluster headache;
      6. Medication-overuse headache;
      7. Rare headache disorders & facial pain;
      8. When to see a specialist for secondary headaches

There is still a lot we don’t know about managing headache disorders, and they are often dismissed as ‘just a headache’ – even though chronic headaches can be a disabling condition for some patients. Through funding research, we hope that we can raise the profile of headache disorders and contribute towards discovering life-changing new treatments.

Key terms

TermDefinition
Primary headacheDistinct headache disorders that occur on their own and aren’t the result of another health condition (i.e. migraine, cluster headache).
Secondary headacheHeadaches occurring due to another health condition (common causes are sinusitis and head injuries, more severe cases include stroke or infections).
Painful cranial neuropathiesThis includes the trigeminal neuralgia and persistent idiopathic facial pain. These are very rare but extremely painful, and recognising the symptoms is important so that patients can understand their condition.
Acute treatmentMedications designed to treat headache & any associated symptoms, taken at the onset of an attack.
Preventive treatmentLifestyle changes or medications intended to reduce the frequency and severity of attacks. Lifestyle changes include techniques like cognitive behavioural therapy and meditation.
EpisodicHeadache disorders causing headache on 14 days or less per month (in migraine and tension-type headache).
Headaches occurring in periods from 7 days to one year, separated by pain free periods lasting at least 3 months (in cluster headaches).
ChronicHeadache disorders causing headache on 15 or more days per month for more than 3 months (in migraine and tension-type headache)
Headaches occurring for one year of longer without remission, or with remission periods lasting less than 3 months (in cluster headaches).
PersistentSecondary headache disorders of more than 3 months duration.

  

1) Diagnosis: why do I have a headache?

Before a doctor can start to treat your headache, they will need to understand what is causing your headache. The International Headache Society recognises over 200 headache types, although the two most common types of primary headaches are migraine and tension-type headache (TTH). Cluster headache and other trigeminal autonomic cephalalgias (TACs) are less common, but are extremely painful, and recognising symptoms early is important.

You can use our headache types directory to identify what your symptoms might mean before consulting a doctor to confirm the diagnosis. It’s helpful to keep a headache diary in the weeks leading up to your appointment, recording the number of headache days, severity, and any relevant symptoms. This will help your doctor look for any patterns or triggers, and will ensure you don’t forget to tell them about any specific symptoms.  

Symptoms of primary headache disorders (1)

MigraineTension-type headache (TTH)Cluster headache (CH)
Temporal patternEpisodic migraine: recurrent attacks lasting from 4-72hrs. Frequency is often 1-2/month but can vary from 1/year to 2/week. Freedom from symptoms between attacks.Frequent episodic TTH: recurrent attacks lasting a few hours to a few days. 1-14 headache days per month with freedom from symptoms between attacks.Episodic CH: frequent short-lasting attacks (at least 1 per day lasting 15-180 minutes). They recur in 6-12 week bouts, once or twice a year, then remit for 3 or more months.
Chronic migraine: headache on 15 or more days/month, with migrainous features on at least 8 days/month.Chronic TTH: 15 or more days affected per month (often daily & unremitting).Chronic CH: similar, but without remission between bouts.
Typical headache characteristicsPain is often unilateral and pulsating.Can be unilateral but pain is more often generalised. It may spread to the neck and is typically described as pressure or tightness.Strictly unilateral (although can occasionally switch sides), pain is around the eye or over the temple.
Headache intensityTypically moderate to severe.Typically moderate to severe.Extremely severe.
Associated symptomsAura (in a minority of attacks). Nausea and/or vomiting, light sensitivity, or sound sensitivity are all common.Frequent episodic TTH: no typical other symptoms, except for possible light/sound sensitivity.
Chronic TTH: may cause mild nausea, but not vomiting.
Any or all of the following autonomic features: red and/or watering eye, running or blocked nostril, or drooping eyelid. This occurs only on the same side as the head pain.
Reactive behaviourAvoidance of physical activity (maybe bed rest), preference for dark and quiet.None specific.Marked agitation, unable to lie still during attacks.

 

2) General approaches toward headache treatment plans

In most cases, headache can be effectively managed through medication or managing triggers. If you kept a headache diary in order to establish a diagnosis, you might find the answer to managing your headache is there – diaries can show patterns (i.e. menstrual migraine, seasonal cluster headache), triggers, lifestyle and behavioural factors, and help you recognise how much headache days impact your life.

Most headache disorders have guidelines for acute and preventive treatment. Due to the risk of medication overuse headache, preventive treatments are recommended for patients with chronic disorders. Over-the-counter medications like paracetamol or ibuprofen can be used safely for episodic headache, by following the dosage guidelines and not using them more than three times a week (3). 

One of the most important things in headache management is finding an effective treatment with minimal side effects. This is why an ongoing relationship with your doctor is important. Not all medications will be effective, and not all triggers can be avoided. Managing headache will be a balance of pharmaceutical and lifestyle changes to develop a treatment plan that works for you.

 

3) Migraine

Migraine is the most common reason that patients seek professional help for headache management (2). It is a complex disorder, and treatment can often involve a lot of trial and error in trying to find something that works. Some of the options available include:

  • Acute treatments (over-the-counter and prescription)
  • Preventive medications (including oral medications, calcitonin gene-related peptide antibodies [CGRPs] and Botox)
  • Lifestyle and behavioural changes to avoid triggers
  • Nerve stimulation devices
  • Complementary treatment (massage, meditation and more)

The good news is that there are some very effective migraine medications, with the most well-known types being triptans (an acute medication). There are five types of triptans in Australia, and studies have found that between 42-76% of patients will respond to at least one type of triptan (4). Conventional preventives include blood pressure medications, antidepressants, and antiepileptics.

Most doctors will recommend a combination of pharmaceutical treatment and lifestyle management. While it’s good to recognise triggers, particularly early on in treatment, it’s important to accept that not every trigger can be controlled(1). Many migraine patients require some kind of medication, and recognising this will help you avoid the stress of trying to manage migraine solely through lifestyle changes. 

You can find a more comprehensive guide to migraine management here.

 

4) Tension-type headache (TTH)

Tension-type headache (TTH) is the most common headache, and is generally described as ‘featureless’ due to the lack of accompanying symptoms. Most people have experienced a tension-type headache at some point, however for some people it can be frequent or chronic. 

Patients with infrequent headaches (less than two days per week) can usually use over-the-counter painkillers (1). Unlike migraine, there aren’t any TTH-specific medications available for acute treatment, and triptans won’t be effective for TTH. 

If you have more than two headache days per week, consider:

  • Psychological intervention (i.e. cognitive behavioural therapy) to reduce stress, which might be causing your frequent headaches
  • Increasing physical activity or movement throughout the day
  • Improving sleep duration, quality and consistency
  • Reducing the quantity of processed foods, examine dietary triggers
  • Increase hydration levels throughout the day with water or herbal teas 
  • Preventive medication (depending on your doctor’s advice)

The preventive medications for TTH are primarily used as antidepressants, but can be effective in preventing headache provided there aren’t any side effects.

Preventive drugs with evidence of efficacy in frequent episodic or chronic TTH (1)

DrugDosageNotes
Amitriptyline10-100mg at nightDrug of choice for TTH. Intolerance is reduced by starting at a low dose (10mg) and increasing by 10-25mg each 1-2 weeks.
Nortriptyline10-100mg at nightFewer anticholinergic side-effects (i.e. constipation, dry mouth, agitation, etc) but less evidence of efficacy.
Mirtazapine15-30mg once dailySecond-line option
Venlafaxine75-150mg once dailyThird-line option

 

5) Cluster headache

Cluster headache is a type of trigeminal autonomic cephalalgia (TAC), characterised by short-lasting but extremely severe headache. The pain is localised around one eye and can be accompanied by bloodshot, irritated and swollen eyes; restlessness; sweating; and congestion. 

Due to the short attacks, most acute medications are not recommended for cluster headache. Over-the-counter painkillers will only kick in after the attack ends, so these should be avoided if you are experiencing cluster headache. Some triptans are used, but they need to be injected to work quickly enough.

Preventive medications play a bigger role in management, but they need to be started in between clusters. Seeing a headache specialist may be appropriate for people living with cluster headache. If you are experiencing these symptoms, ask your GP for a referral to a neurologist or headache specialist.

Current landscape for cluster headache treatment (5)

Acute treatmentPreventive treatmentInterim treatment
Pharmaceutical treatmentSumatriptan subcutaneous injection
Zolmitriptan nasal spray
Sumatriptan nasal spray
Oxygen
Verapamil
Topiramate
Melatonin
Greater occipital nerve block
Neuromodulation techniquesNon-invasive vagus nerve stimulator (for episodic CH)Non-invasive vagus nerve stimulator
Sphenopalatine ganglion microstimulator
Medications being phased outLithiumOral prednisone

 

6) Medication-overuse headache (MOH)

Medication-overuse headache (MOH) is characterised by headache occurring on 15 or more days per month, and often begins as episodic migraine or TTH (1). Some medications can aggravate headache disorders, including: 

  • Simple analgesics (ibuprofen, paracetamol, aspirin)
  • Triptans
  • Opioids
  • Combination medications (any of the above combined with caffeine)

If you have been using any of the above medications to treat these headache disorders and have experienced an increase in headache days, it could be due to MOH. Most doctors will try to prevent MOH through patient education, but it can be easy to overuse medication without realising. 

The only way to manage MOH is to stop taking the medication as quickly as possible, and early intervention has the best results. Your doctor might recommend (1):

  • Stopping immediately (cold turkey)
  • Tapering off your intake, more commonly advised for opioids
  • Replacing the overused medication with another acute treatment alternative and establishing a more robust plan to help prevent future attacks 

Unfortunately, your headache will likely worsen for 1-2 weeks with withdrawal symptoms, but the good news is that the long-term results are generally good. Once your headache has reverted to the previous frequency of episodic TTH or migraine, you can work on a new treatment plan with your doctor that prioritises preventive strategies.

 

7) Rare headache disorders & facial pain

These disorders include trigeminal neuralgia and persistent idiopathic facial pain (PIFP). Trigeminal neuralgia involves recurrent electric-shock-like pains in one side of the face, and can be triggered by seemingly innocuous stimuli (even brushing your hand against your face). PIFP causes dull, aching, poorly localised facial pain, which occurs for over two hours per day (1).

While they have different symptoms, both of these rare disorders have a huge impact on patients, and can be physically, psychologically and socially debilitating. General painkillers are not effective for these disorders. If you are experiencing these symptoms, ask your GP for a referral to a specialist – treatment is complex, and a specialist will be able to screen for possible other causes of the pain.

Trigeminal neuralgia and PIFP both have preventive medications available. These need to be taken at a low dose to begin with, and gradually increased due to possible side effects. Many people find these preventives helpful, and if the pain stops altogether patients can possibly taper down the dosage and eventually cease medication (1).

 

8) Secondary headaches

In some cases, headaches can be a symptom of something more serious. If you experience any of the following symptoms without an explanation (6), it’s best to speak to your doctor as soon as possible. 

  • Thunderclap headache (intense, exploding and hyperacute onset)
  • Progressive headache, worsening over weeks
  • Persistent morning headache with nausea
  • Headache associated with:
    • Unexplained fever
    • Change in personality or consciousness
    • Neck stiffness
    • Neurologic symptoms: double vision, visual changes, tinnitus, weakness, changes in sensation, changes in balance
  • New onset headache for:
    • Patients with history of cancer
    • Patients with immunodeficiency (including HIV)
    • Adults over 50
    • Anyone with family history of glaucoma
    • Patients during pregnancy
  • Aura symptoms that
    • Last longer than an hour
    • Include motor weakness
    • Are different from previous aura
    • Occur for the first time on using oral contraceptive pill

Source: references 1 & 2

Most people are familiar with mild headaches that occur infrequently. But when headache becomes more common, disruptive and debilitating, it’s important to seek care. With over 200 headache types, the treatment strategy is greatly informed by the diagnosis – even treatment between the major headache types listed here can be so different. That is why it is critical for an accurate diagnosis before an effective treatment plan can be put in place to reduce the frequency and severity of your headache. 

 

References

 

      1. TJ Steiner et al, 2019, Aids to management of headache disorders in primary care (2nd edition). https://doi.org/10.1186/s10194-018-0899-2 
      2. WJ Becker et al, 2015, Guideline for primary care management of headache in adults. PMID: 26273080. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4541429/pdf/0610670.pdf 
      3. F Ahmed, 2012, Headache disorders: differentiating and managing the common subtypes. https://doi.org/10.1177%2F2049463712459691 
      4. C Cameron et al, 2015, Triptans in the Acute Treatment of Migraine: A Systematic Review and Network Meta-Analysis. https://doi.org/10.1111/head.12601 
      5. DY Wei et al. 2019, Managing cluster headache. http://dx.doi.org/10.1136/practneurol-2018-002124
      6. CC Chiang et al. 2020, Diagnosing secondary headaches. Practical Neurology, vol 19, no.4 p31-40
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