Management of Headache
Publication Date: September 30, 2023
Last Updated: October 12, 2023
Medication Overuse Headache Screening and Other Considerations
We suggest providers assess for and consider the following high-risk factors for medication overuse headache in patients with headache (in order of relative impact):
- Headache frequency (greater than or equal to 7 days per month)
- Migraine diagnosis
- Medication use: frequent use of anxiolytics, analgesics (for any condition, including use of opioids or non-opioid analgesics for acute treatment of migraine), or sedative hypnotics
- History of anxiety or depression, especially in combination with musculoskeletal complaints or gastrointestinal complaints
- Physical inactivity
- Sick leave of greater than 2 weeks in the last year
- Self-reported whiplash
- Smoking (tobacco use)
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Pharmacotherapy
Headache - Preventive
There is insufficient evidence to recommend for or against coenzyme Q10, feverfew, melatonin, omega-3, vitamin B2, or vitamin B6 for the prevention of headache. (Neither for or against)
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There is insufficient evidence to recommend for or against fluoxetine or venlafaxine for the prevention of headache. (Neither for or against)
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Migraine - Preventive
We recommend candesartan or telmisartan for the prevention of episodic migraine. (Strong for)
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We recommend erenumab, fremanezumab, or galcanezumab for the prevention of episodic or chronic migraine. (Strong for)
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We suggest intravenous eptinezumab for the prevention of episodic or chronic migraine. (Weak for)
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We suggest lisinopril for the prevention of episodic migraine. (Weak for)
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We suggest oral magnesium for the prevention of migraine. (Weak for)
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We suggest topiramate for the prevention of episodic and chronic migraine. (Weak for)
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We suggest propranolol for the prevention of migraine. (Weak for)
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We suggest valproate for the prevention of episodic migraine. (Weak for)
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We suggest memantine for the prevention of episodic migraine. (Weak for)
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We suggest atogepant for the prevention of episodic migraine. (Weak for)
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We suggest onabotulinumtoxinA injection for the prevention of chronic migraine. (Weak for)
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We suggest against abobotulinumtoxinA or onabotulinumtoxinA injection for the prevention of episodic migraine. (Weak against)
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There is insufficient evidence to recommend for or against rimegepant for the prevention of episodic migraine. (Neither for or against)
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We suggest against the use of gabapentin for the prevention of episodic migraine. (Weak against)
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There is insufficient evidence to recommend for or against levetiracetam for the prevention of episodic migraine. (Neither for or against)
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Migraine - Abortive
We recommend eletriptan, frovatriptan, rizatriptan, sumatriptan (oral or subcutaneous), the combination of sumatriptan and naproxen, or zolmitriptan (oral or intranasal) for the acute treatment of migraine. (Strong for)
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We recommend aspirin/acetaminophen/caffeine for the acute treatment of migraine. (Strong for)
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We suggest acetaminophen, aspirin, ibuprofen, or naproxen for the acute treatment of migraine. (Weak for)
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We suggest rimegepant or ubrogepant for the acute treatment of migraine. (Weak for)
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We suggest against intravenous ketamine for the acute treatment of migraine. (Weak against)
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There is insufficient evidence to recommend for or against lasmiditan for the acute treatment of migraine. (Neither for or against)
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Tension-Type Headache - Preventive
We suggest amitriptyline for the prevention of chronic tension-type headache. (Weak for)
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We suggest against botulinum/neurotoxin injection for the prevention of chronic tension-type headache. (Weak against)
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Tension-Type Headache - Abortive
We suggest ibuprofen (400 mg) or acetaminophen (1,000 mg) for the acute treatment of tension-type headache. (Weak for)
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Cluster Headache - Preventive
We suggest galcanezumab for the prevention of episodic cluster headache. (Weak for)
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We suggest against galcanezumab for the prevention of chronic cluster headache. (Weak against)
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There is insufficient evidence to recommend for or against verapamil for the prevention of episodic or chronic cluster headache. (Neither for or against)
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Cluster Headache - Abortive
We suggest subcutaneous sumatriptan (6 mg) or intranasal zolmitriptan (10 mg) for the acute treatment of cluster headache. (Weak for)
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We suggest the use of normobaric oxygen therapy for the acute treatment of cluster headache. (Weak for)
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Medication Overuse Headache
There is insufficient evidence to recommend for or against the addition of any specific preventive agent or withdrawal strategy to guide the treatment of medication overuse headache. (Neither for or against)
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Injections, Procedures, and Invasive Interventions
We suggest greater occipital nerve block for the acute treatment of migraine. (Weak for)
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There is insufficient evidence to recommend for or against greater occipital nerve block for the prevention of chronic migraine. (Neither for or against)
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There is insufficient evidence to recommend for or against supra orbital nerve block for acute treatment of migraine. (Neither for or against)
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There is insufficient evidence to recommend for or against intravenous antiemetics (i.e., intravenous chlorpromazine, intravenous metoclopramide, intravenous prochlorperazine), intravenous magnesium, or intranasal lidocaine for the acute treatment of headache. (Neither for or against)
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There is insufficient evidence to recommend for or against pulsed radiofrequency procedure of the upper cervical nerves or sphenopalatine ganglion block for the treatment of chronic migraine. (Neither for or against)
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We suggest against an implantable sphenopalatine ganglion stimulator for the treatment of cluster headache. (Weak against)
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We suggest against patent foramen ovale closure for the treatment or prevention of migraine. (Weak against)
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Non-pharmacologic Therapy
We suggest non-invasive vagus nerve stimulation for the acute treatment of episodic cluster headache. (Weak for)
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We suggest physical therapy for the management of tension-type, migraine, or cervicogenic headache. (Weak for)
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We suggest aerobic exercise or progressive strength training for the prevention of tension-type and migraine headache. (Weak for)
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There is insufficient evidence to recommend for or against the following behavioral interventions for the treatment and/or prevention of headache:
- Biofeedback and smartphone application-based heartrate variability monitoring
- Cognitive behavioral therapy
- Mindfulness-based therapies
- Progressive muscle relaxation
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There is insufficient evidence to recommend for or against acupuncture, dry needling, or yoga for the treatment and/or prevention of headache. (Neither for or against)
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There is insufficient evidence to recommend for or against dietary trigger avoidance for the prevention of headache. (Neither for or against)
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We suggest against immunoglobulin G antibody testing for dietary trigger avoidance for the prevention of headache. (Weak against)
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There is insufficient evidence to recommend for or against any form of neuromodulation for the treatment and/or prevention of migraine:
- Non-invasive vagus nerve stimulation
- Supraorbital, or external trigeminal, nerve stimulation
- Remote electrical neurostimulation
- External combined occipital and trigeminal neurostimulation system
- Repetitive transcranial magnetic stimulation
- Transcranial direct current stimulation
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Comparative Effectiveness and Combination Therapies
There is insufficient evidence to recommend for or against choosing a specific treatment strategy for posttraumatic headache. (Neither for or against)
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There is insufficient evidence to recommend for or against any specific medication over another for the acute treatment of migraine. (Neither for or against)
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There is insufficient evidence to recommend for or against any specific medication over another for the prevention of migraine headache, tension headache, or cluster headache. (Neither for or against)
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There is insufficient evidence to recommend for or against any specific combination of therapies for the prevention of headache. (Neither for or against)
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Recommendation Grading
Overview
Title
Management of Headache
Authoring Organization
Veterans Health Administration / Department of Defense
Publication Month/Year
September 30, 2023
Last Updated Month/Year
April 1, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Management
Diseases/Conditions (MeSH)
D006261 - Headache, D020773 - Headache Disorders, D014493 - United States Department of Veterans Affairs, D058014 - Veterans Health, D000081324 - Veterans Health Services
Keywords
headache, veteran
Supplemental Methodology Resources
Methodology
Number of Source Documents
388
Literature Search Start Date
March 5, 2019
Literature Search End Date
August 15, 2022