Chapter 35: Headaches – Acute & Preventive Pharmacotherapy

TTH, the most common type, is characterized by mild-to-moderate bilateral, pressing or tightening pain, often linked to disrupted sleep or environmental stressors, and is typically treated using simple analgesics like acetaminophen or nonsteroidal antiinflammatory drugs (NSAIDs). Conversely, migraine is a disabling neurobiologic syndrome involving severe, throbbing pain, commonly unilateral, and associated with photophobia, phonophobia, and nausea; its mechanism involves the trigeminovascular system and the release of calcitonin gene-related peptide (CGRP). Acute migraine therapy relies on maximizing effectiveness by treating early, often employing migraine-specific agents like triptans (5-HT1 receptor agonists) or the newer, non-vasoconstricting Ditans (like lasmiditan) and Gepants (CGRP receptor antagonists like ubrogepant and rimegepant), which are attractive options for patients with cardiovascular risks. Long-term preventive therapy is indicated for frequent headaches or medication overuse, utilizing agents such as specific beta blockers (propranolol, metoprolol), anticonvulsants (topiramate, divalproex), or advanced injectable therapies like CGRP monoclonal antibodies and OnabotulinumtoxinA (for chronic migraine). A critical theme throughout treatment is the prevention of medication overuse headache (MOH) by strictly limiting analgesic use, especially opioids and butalbital-containing compounds, and providing thorough patient education on trigger identification and adherence to prophylactic regimens. Special considerations are detailed for pediatric patients, older adults (where new headaches warrant evaluation for organic disease), and women, particularly regarding the use of contraindicated agents during pregnancy.