What is the best initial intervention for a unilateral headache with dizziness and nausea?

Management of Unilateral Headache with Dizziness and Nausea

For a patient presenting with unilateral headache, dizziness, and nausea, NSAIDs (such as ibuprofen 400-800mg or naproxen 500-550mg) should be used as first-line acute treatment, administered as early as possible during the attack. 1, 2

Initial Assessment and Diagnosis

The constellation of unilateral headache with dizziness and nausea strongly suggests migraine as the most likely diagnosis. According to diagnostic criteria:

• Migraine without aura typically presents with:

  • Unilateral location
  • Moderate to severe intensity
  • Associated nausea and/or vomiting
  • Photophobia and phonophobia 1

• Vestibular migraine should be considered when dizziness is prominent 1

Red Flags Requiring Urgent Evaluation

Be vigilant for warning signs requiring immediate further evaluation:

• Sudden, severe "thunderclap" headache
• Headache with fever, stiff neck, confusion
• Headache after head trauma
• New headache with neurological symptoms
• Headache worsened with Valsalva maneuver 2

Treatment Algorithm

1. First-Line Acute Treatment

• NSAIDs:
  • Ibuprofen 400-800mg OR
  • Naproxen 500-550mg 1, 2
  • Administer as early as possible in the attack for maximum efficacy

2. Second-Line Acute Treatment (if NSAIDs inadequate)

• Triptans:
  • Sumatriptan (25mg, 50mg, or 100mg)
  • Clinical trials show significant headache response at 2 and 4 hours compared to placebo 3
  • 50mg and 100mg doses show better response than 25mg 3

3. Adjunct Treatment for Nausea

• Prokinetic antiemetics:
  • Domperidone OR
  • Metoclopramide 1
  • Particularly important when nausea is prominent

4. Medications to Avoid

• Oral ergot alkaloids (poorly effective and potentially toxic)
• Opioids and barbiturates (questionable efficacy, risk of dependency)
• Acetaminophen alone (limited evidence for efficacy) 1, 2

Follow-up Considerations

If headaches occur frequently (≥2 days/month with significant disability), consider preventive therapy:

• First-line preventive options include:
  • Propranolol (80-240 mg/day)
  • Topiramate
  • Amitriptyline 2

Important Clinical Pearls

1. Early intervention is crucial: Treating at the first sign of headache improves outcomes 1, 2

2. Medication overuse risk: Limit acute medications to ≤10 days per month to prevent medication overuse headache 2

3. Non-pharmacological approaches: Maintaining regular sleep patterns, meal times, adequate hydration, and stress management techniques can help prevent recurrence 2

4. Consider vestibular migraine: If dizziness is a prominent feature, this diagnosis should be specifically considered, as it can mimic Ménière's disease 1

5. Track symptoms: Using a headache diary to monitor frequency, severity, and medication use can help guide treatment adjustments 2

The evidence strongly supports starting with NSAIDs for acute treatment, with triptans as second-line therapy if response is inadequate, while addressing the accompanying nausea with appropriate antiemetics.