Headache Treatment Guidelines of the Portuguese Headache Society – 2021

Abstract

Background: Therapeutic guidelines are useful tools in clinical practice. We updated previous Portuguese Headache Society Therapy Guidelines. Objectives: To provide healthcare professionals updated evidence-based guidance on treatments for the primary headaches, trigeminal neuralgia and medicationoveruse headache. Methods: This statement authored by a group of experts from the Portuguese Headache Society, was based on a review of existing national headache guidelines, results of relevant clinical trials, review of international guidelines and in case of rare diseases expert opinion and results from small case series. Results: Nonpharmacological interventions for headache management such as general measures, avoiding medication overuse and alternative therapies such as cognitive-behavioural techniques, biofeedback and acupuncture are addressed. Evidence based acute migraine drug treatment (nonspecific – simple analgesics and nonsteroidal anti-inflammatories or specific – triptans) guidance is provided. For episodic migraine, preventive therapy criteria are listed and general rules for using first line oral preventives with proven efficacy (beta-blockers, antiepileptic drugs, flunarizine and tricyclic antidepressants) are provided. Second line preventive drugs such as monoclonal antibodies anti-CGRP (calcitonin gene related peptide), fremanezumab, galcanezumab and eptinezumab, or anti CGRP receptor, erenumab, are also addressed. In chronic migraine, all patients should be on prophylactic treatment whether the first line oral drugs (topiramate) or in its failure with second line drugs: OnabotulinumtoxinA or anti-CGRP therapies. Acute and preventive guidelines for tension type headache and trigeminal-autonomic cephalalgias are provided. In what concerns trigeminal neuralgia evidence based pharmacologic guidance is discussed but other interventions such as surgery should be considered in refractory patients. Evidence based management of medication overuse headache is addressed. Special populations such as children, pregnant or lactating women and elderly patients with multiple comorbidities and polypharmacy deserve specific guidelines. Relevant drug interactions, especially pharmacokinetic interactions with headache preventive and abortive drugs are explored. Conclusion: This statement provides evidence based updated headache treatment guidelines.