Morning Frontal Headache Management
For morning frontal headaches lasting 4-5 hours, start with over-the-counter NSAIDs (ibuprofen, diclofenac, or aspirin) as first-line treatment, taken as early as possible when symptoms begin. 1
Initial Assessment
Before initiating treatment, evaluate for red flag features that would require urgent neuroimaging or specialist referral:
- Headache that awakens from sleep is a concerning feature that warrants lower threshold for investigation 1, 2
- New headache in patients over age 50 requires neuroimaging 1, 3
- Headache worsened by Valsalva maneuver suggests increased intracranial pressure 1
- Any focal neurologic signs, papilledema, or neck stiffness mandate immediate evaluation 3
- Progressively worsening pattern over time requires investigation 1, 2
The morning timing and 4-5 hour duration are consistent with migraine without aura, which typically lasts 4-72 hours when untreated 1. The frontal location alone does not exclude migraine, as migraine can be bilateral or frontal rather than strictly unilateral 1.
Diagnostic Criteria Consideration
Determine if the headache meets criteria for migraine without aura 1:
- At least 5 attacks lasting 4-72 hours
- At least 2 of: unilateral location, pulsating quality, moderate-to-severe intensity, or aggravation by routine activity
- At least 1 of: nausea/vomiting OR photophobia and phonophobia
Acute Treatment Algorithm
First-Line Treatment
NSAIDs with proven efficacy should be used initially 1:
- Ibuprofen, diclofenac potassium, or acetylsalicylic acid (aspirin)
- Administer as early as possible during the attack for maximum efficacy 1
- Paracetamol (acetaminophen) has less efficacy and should only be used if NSAIDs are not tolerated 1
Second-Line Treatment
If NSAIDs provide inadequate relief after adequate trial, prescribe a triptan 1:
- All triptans have well-documented effectiveness
- Most effective when taken early in the attack while headache is still mild 1
- If one triptan fails, others may still provide relief 1
- For rapid-onset or severe attacks with vomiting, subcutaneous sumatriptan can be useful 1
Managing Relapses
If symptoms return within 48 hours after initial successful treatment 1:
- Repeat the triptan dose, OR
- Combine triptan with fast-acting NSAID formulations (naproxen sodium, ibuprofen lysine, or diclofenac potassium)
Critical Medication Overuse Warning
Limit acute treatment to no more than twice weekly to prevent medication-overuse headaches 4:
- Triptans used ≥10 days/month can cause rebound headaches 4
- NSAIDs used ≥15 days/month can cause rebound headaches 4
- Avoid opioids and butalbital-containing medications entirely due to dependency and rebound risks 4
When to Consider Preventive Therapy
Preventive medication should be initiated if headaches occur more than 2 times per week 1. This prevents medication-overuse headaches and reduces overall headache burden.
First-line preventive options include 1:
- Beta-blockers: propranolol 80-160 mg daily, metoprolol 50-100 mg twice daily, or atenolol 25-100 mg twice daily
- Angiotensin II-receptor blocker: candesartan 16-32 mg daily
- Anticonvulsant: topiramate 50-100 mg daily
Referral Indications
Refer to neurology if 5:
- Uncertain diagnosis
- Poor response to preventive strategies
- Persistent aura symptoms
- Associated motor weakness
- Unremitting headache despite appropriate treatment