What are the treatment options for headaches and pain in the temples and back of the neck?

Treatment Options for Headaches in the Temples and Back of the Neck

For headaches involving the temples and back of the neck, NSAIDs are the first-line treatment for mild to moderate pain, while triptans are recommended for moderate to severe pain that doesn't respond to NSAIDs. 1

Diagnosis Considerations

• Headaches affecting the temples and back of the neck may represent tension-type headaches, migraines, or cervicogenic headaches 2
• Frequency is important - chronic migraine is defined as 15 or more headaches per month, with at least 8 days having migraine features 1
• Using a headache diary helps track frequency, severity, and medication response 1, 3
• "Red flags" requiring neuroimaging include rapidly increasing headache frequency, uncoordination, focal neurologic signs, headaches that wake the patient from sleep, or abrupt onset of severe headache 1

Acute Treatment Options

First-Line Treatments

• For mild to moderate headaches:
  • NSAIDs: aspirin (650-1,000 mg every 4-6 hours), ibuprofen (400-800 mg every 6 hours), naproxen sodium (275-550 mg every 2-6 hours) 1, 4
  • Combination medications containing acetaminophen, aspirin, and caffeine 1, 5

Second-Line Treatments

• For moderate to severe headaches or those not responding to NSAIDs:
  • Triptans (sumatriptan, rizatriptan, zolmitriptan) 1, 6
  • Sumatriptan has demonstrated efficacy with 50-62% of patients achieving headache response at 2 hours compared to 17-27% with placebo 6
  • Caution: Triptans are contraindicated in patients with cardiovascular disease due to vasoconstrictive properties 6, 7

Adjunctive Treatments

• Metoclopramide or prochlorperazine for associated nausea and as synergistic analgesics 1, 4
• For severe migraine not responding to other treatments, consider rescue medications 1

Preventive Treatment

When to Consider Prevention

• Preventive therapy should be initiated when patients experience:
  • Two or more headaches per month with disability lasting ≥3 days 3
  • 15 or more headache days per month (chronic migraine) 1

Medication Options

• First-line preventive options:

  • Topiramate - shown to be efficacious in randomized controlled trials for chronic migraine 1
  • Candesartan or telmisartan for episodic migraine 1
  • Propranolol for migraine prevention 1

• For chronic migraine:

  • OnabotulinumtoxinA (Botox) - FDA-approved specifically for chronic migraine prophylaxis 1
  • CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) - effective for patients who have failed other preventive medications 1

• Other options:

  • Amitriptyline - particularly useful for patients with comorbid depression or sleep disturbances 1
  • Valproate for episodic migraine 1
  • Oral magnesium 1

Non-Pharmacological Approaches

• Manual treatment of the neck and back (mobilization/manipulation) may be beneficial for headaches with cervical involvement 1, 8
• Vestibular rehabilitation for associated dizziness or balance issues 1
• Graded physical exercise can help with physical deconditioning and autonomic instability 1
• Psychological interventions including cognitive behavioral therapy for comorbid anxiety/depression 1

Important Cautions and Pitfalls

• Medication overuse headache risk:

  • Limit acute treatments to no more than twice weekly 1, 3, 4
  • Assess for risk factors: headache frequency ≥7 days/month, migraine diagnosis, frequent use of anxiolytics or analgesics 1
  • Treatment requires withdrawal of overused medication; abrupt withdrawal is preferred except for opioids 1

• Avoid opioids:

  • Opioid analgesics should be avoided for chronic headaches due to risk of dependency, rebound headaches, and eventual loss of efficacy 1, 4

• Triptan contraindications:

  • Avoid in patients with coronary artery disease, Prinzmetal's angina, or uncontrolled hypertension 6
  • Can cause serotonin syndrome when combined with SSRIs, SNRIs, TCAs, or MAO inhibitors 6

When to Refer to a Specialist

• Chronic migraine management is challenging and often requires referral to specialist care 1
• Consider referral when patients have failed multiple preventive medications or have complex comorbidities 1
• Patients with concerning neurological symptoms or atypical presentations should be referred for further evaluation 1