• Primary headache disorders
  • Primary headaches occur spontaneously with an unknown cause, are stereotypical, and may recur.
  • Examples include migraine, cluster type headache, and tension-type headache.
• Secondary headache disorders
  • Secondary headache presents as a new onset and parallel to an illness that is known to cause headaches.
  • Examples include head and/or neck trauma; a cranial or cervical vascular disorder; a nonvascular intracranial disorder; substance use and/or withdrawal, infection; homeostasis illness; illness of the cranium, neck, eyes, ears, nose, sinuses, mouth, or other facial or cervical structure; or a psychiatric disorder.
• Assessment should be made to determine whether the patient is experiencing a primary headache versus a secondary headache.
  • Consider duration and frequency; characteristics such as severity, location, quality, and what activities exacerbate it; features such as light sensitivity or noise aggravating the headache; and nausea and vomiting or autonomic dysfunction.
• The guiding principle in assessing for secondary headache is determining whether there is a parallel cause that can be associated with headache onset. Resolution of the parallel disorder may in turn resolve the headache.

• Assess patients with headache for medication overuse headache. The following are indicators:
  • Headache frequency (7 or more days per month)
  • Migraine diagnosis
  • Sick leave of more than 2 weeks in the last year
  • Recurrent use of analgesics, anxiolytics, or sedatives
  • Inactivity
  • History of whiplash as reported by the patient
  • Depression or anxiety, without gastrointestinal or musculoskeletal ailments
  • Absenteeism from work for more than two weeks in the last year
  • Smoking
• There is no recommendation for or against a specific medication withdrawal treatment or strategy.

Headache - Preventive

• Insufficient data is available to recommend for or against the following for the prevention of headaches:
  • Coenzyme Q10
  • Feverfew
  • Melatonin
  • Omega-3
  • Vitamin B2
  • Vitamin B6
  • Fluoxetine
  • Venlafaxine

Migraine

• Candesartan or telmisartan is recommended for episodic migraine.
• Erenumab, fremanezumab, or galcanezumab is recommended for episodic or chronic migraine.
• Intravenous eptinezumab is suggested for episodic or chronic migraine.
• Lisinopril is suggested for episodic migraine.
• Oral magnesium is suggested (nonspecific to the type of migraine).
• Topiramate is suggested for episodic migraine and chronic migraine.
• Propranolol is suggested (nonspecific to the type of migraine).
• Valproate is suggested for episodic migraine.
• Memantine is suggested for episodic migraine.
• Atogepant is suggested for episodic migraine.
• OnabotulinumtoxinA injection is suggested for chronic migraine.
• OnabotulinumtoxinA or abobotulinumtoxinA injection is not suggested for episodic migraines.
• Gabapentin is not suggested to prevent episodic migraines.
• There is no recommendation either for or against the following:
  • Rimegepant for the prevention of episodic migraine.
  • Levetiracetam for episodic migraine.

• For acute treatment, eletriptan, frovatriptan, rizatriptan, SUMAtriptan (oral or subcutaneous), the combination of SUMAtriptan and naproxen, or zolmitriptan (oral or intranasal) is recommended.
• A combination of aspirin, acetaminophen, and caffeine are recommended for acute treatment.
• The use of intravenous ketamine is not suggested.
• Insufficient data is available to make a recommendation for the use of lasmiditan.
• The following acute therapies are suggested:
  • Rimegepant or urbrogepant
  • Ibuprofen, aspirin, acetaminophen, and naproxen

Tension-Type Headache

• Amitriptyline for chronic tension-type headaches is suggested.
• Botulinum/neurotoxin injection is not suggested for chronic tension-type headaches.

• Ibuprofen 400 mg or acetaminophen 1000 mg is suggested as acute therapy.

Cluster Headache

• Galcanezumab is suggested for episodic cluster headaches; however, galcanezumab is not suggested for chronic cluster headaches.
• Insufficient data is available to make a recommendation for the use of verapamil to prevent episodic or chronic cluster headaches.

• Subcutaneous sumatriptan (6 mg) or intranasal zolmitriptan (10 mg) is suggested for acute treatment.
• Normobaric oxygen therapy is suggested for acute treatment.

Medication Overuse

• Insufficient data is available to make a recommendation for the use of any specific preventive or withdrawal strategy to direct treatment.

• For the acute treatment of migraine, a greater occipital nerve block is suggested.
• Implantable sphenopalatine ganglion stimulator is not suggested for the treatment of cluster headaches.
• Patent foramen ovale closure is not suggested for the prevention or treatment of migraines.
• Insufficient data is available to recommend the following:
  • Greater occipital nerve block for the prevention of chronic migraines.
  • Supraorbital nerve block for the acute treatment of migraines.
  • Intravenous antiemetics, such as chlorpromazine, metoclopramide, and prochlorperazine, intravenous magnesium, or intranasal lidocaine for acute therapy of headaches.
• Pulsed radiofrequency procedure of the upper cervical nerves or sphenopalatine ganglion block for the treatment of chronic migraines.

• Noninvasive vagus nerve stimulation is suggested for the acute treatment of episodic cluster headache.
• Physical therapy is suggested for the management of tension-type, migraine, or cervicogenic headache.
• Aerobic exercise or progressive strength training is suggested for the prevention of tension-type and migraine headaches.
• Immunoglobulin G antibody testing for dietary trigger avoidance is not suggested for the prevention of headaches.
• Insufficient data is available to recommend the following:
  • Behavioral interventions for the prevention and/or treatment of headaches, including:
    • Biofeedback and application-based heartrate variability monitoring
    • Progressive muscle relaxation
    • Cognitive behavioral therapy
    • Mindfulness-based therapies
  • Acupuncture, dry needling, or yoga for prevention and/or treatment.
  • Dietary trigger avoidance for the prevention of headaches.
  • Any form of neuromodulation for the prevention and/or treatment of migraines.

• Insufficient data is available to recommend the following:
  • Specific treatment for posttraumatic headache.
  • Any specific medication over another for the acute treatment of migraines.
  • Any specific medication over another for the prevention of migraines, tension headaches, or cluster headaches.
  • Any specific combination of therapies for the prevention of headaches.