Half of adults have at least one headache in a given year, and the practical question is usually the same: what will make this one stop. Migraine alone affects more than one billion people worldwide, but the condition is not one disease. It splits into types that need different first choices.
The base rate matters because a remedy that works for a tension-type headache can be nearly useless in a migraine attack. A dull, pressing pain on both sides of the head, without nausea, usually fits tension-type headache. A throbbing pain on one side, worsened by routine movement and paired with nausea, light sensitivity or sound sensitivity, points toward migraine. Cluster headache is less common and unmistakable: excruciating one-sided pain around the eye, often with tearing and restlessness, arriving in clusters over weeks.
The treatment changes with the type of headache you actually have
The best-studied acute treatments for tension-type headache are aspirin, ibuprofen and paracetamol, sometimes called simple analgesics. In randomized trials, ibuprofen at standard over-the-counter doses gives meaningful pain relief at two hours in roughly half of people, compared with about three in ten after placebo. Aspirin and paracetamol help many people too, though paracetamol is generally the most modest of the three.
Nonsteroidal anti-inflammatory drugs, the NSAIDs that include ibuprofen and naproxen, work by reducing prostaglandin production; that means inflammation and pain signalling drop together. They also carry a risk of stomach irritation, bleeding and reduced kidney function, so people with ulcers, kidney disease or a history of gastrointestinal bleeding should use them with caution. Paracetamol has a different risk profile, mainly liver damage at doses above 4 grams a day from all sources. The right dose is the lowest one that works, taken early while the headache is mild.
Adding caffeine to aspirin or paracetamol improves the effect slightly, but the clock matters. A late-afternoon caffeinated analgesic can disturb sleep, and poor sleep is itself one of the most reliable headache triggers. A cold pack on the forehead or a warm pack on the neck is safe and cheap. The formal evidence is weak, but the harm is minimal and some patients find the cold genuinely analgesic.
For migraine, the branch point changes
A moderate or severe migraine usually needs more than a standard dose of paracetamol. Triptans — sumatriptan, rizatriptan, eletriptan and others — act on serotonin receptors and remain the central acute migraine treatment for adults without heart or vascular disease. They are most effective taken early, while the pain is mild. The American Headache Society describes triptans as established first-line options for many patients, alongside high-dose NSAIDs and the newer gepants.
Gepants — rimegepant and ubrogepant — block a receptor for calcitonin-gene-related peptide, a molecule involved in migraine pain and inflammation. They carry less vascular risk than triptans. Lasmiditan targets a different serotonin receptor without narrowing blood vessels. These drugs expand options for people who cannot take triptans because of coronary artery disease or uncontrolled high blood pressure. Anti-nausea medication such as metoclopramide helps because migraine slows stomach emptying; treating nausea is not comfort care, it speeds the painkiller into the bloodstream.
Some people with mild migraine attacks do well with high-dose aspirin or an NSAID alone. The key is to respect the triptan rules: no second triptan within 24 hours unless a clinician has given specific instructions, and no triptan for anyone with serious vascular disease.
Cluster headache is treated differently from the start
Cluster attacks peak within minutes and often resolve in one to three hours, so swallowed tablets act too slowly. High-flow oxygen through a non-rebreather mask and injectable or intranasal sumatriptan are first-line acute treatments. Verapamil, a calcium-channel blocker, is commonly used as prevention under specialist supervision. The condition is rare enough that it is often missed; the combination of severe one-sided eye pain and agitation should trigger referral, not endless over-the-counter trials.
Frequent attacks change the goal from treatment to prevention
If you need acute medication on ten or more days a month, the treatment has become part of the problem. The World Health Organization warns that regular overuse of acute medicines causes medication-overuse headache, a daily or near-daily headache that persists until the overused drug is stopped. The practical threshold is simple: more than two days a week of painkillers is a signal, not a solution.
Preventive drugs work on attack frequency, not on pain in the moment. Amitriptyline, propranolol, candesartan and topiramate are long-standing choices; for chronic migraine, CGRP monoclonal antibodies and botulinum toxin type A have stronger evidence. Most preventives take four to eight weeks to show benefit, so they reward patience and a diary more than a quick verdict.
A headache specialist I worked with — call her Dr. M — asks every new patient for a two-week diary before changing anything: date, duration, pain score, what was taken, and how much it helped. Two minutes a day separates people who need prevention from people who simply have not tried the right acute drug. It also measures the base rate: eight headache days a month means prevention, two headache days a month means fixing the acute plan.
Non-drug treatments have a narrower but real place
Cognitive behavioural therapy and biofeedback show evidence for reducing migraine frequency, and acupuncture has a modest signal in some trials. Sleep regulation, regular meals and consistent hydration help partly by removing triggers, though hydration is better at preventing dehydration-related headache than at aborting an attack that is already severe. These measures are not substitutes for acute treatment during a full attack; they are the conditions that make future attacks less likely.
Red flags that need urgent care
Most headaches are primary: migraine, tension-type or cluster. Secondary headaches are caused by something else, such as infection, bleeding, a tumour or high blood pressure. The following signals should trigger emergency evaluation rather than another dose of painkiller:
- A sudden severe headache that reaches maximum intensity within a minute, sometimes described as a thunderclap headache.
- A new headache after age 50.
- Fever with a stiff neck or a non-blanching rash.
- Headache after a head injury, with confusion, seizures, weakness, double vision, or worsening drowsiness.
- Headache in a person with cancer, a weakened immune system, or a new blood-clot risk.
Most headaches do not need brain imaging. A clinical evaluation is the first step, and the International Headache Society classification is the language specialists use when a pattern is unclear. The useful question is not whether the pain is severe, but whether the pattern differs from your usual headache.
What this means for your own headache plan
The next headache is a small experiment: treat it early, match the drug to the type, and write down what happened. If you are reaching for pills more than two days a week, the issue is frequency, not this particular attack. That is the point to book a clinical review and bring the two-week record. Start with the diary, not the medicine drawer.
Photo by Gizem Nikomedi on Unsplash