What is the initial treatment for a temporal headache?

Initial Treatment for Temporal Headache

For a patient presenting with temporal headache, you must first rule out temporal arteritis (giant cell arteritis) in anyone over age 50 before initiating standard migraine treatment, as this represents a medical emergency requiring immediate corticosteroids to prevent irreversible vision loss. 1

Critical First Step: Rule Out Temporal Arteritis

In patients over 50 years old with new-onset temporal headache, immediately check an ESR (erythrocyte sedimentation rate) to exclude temporal arteritis—a treatable but potentially devastating condition that can cause permanent blindness if missed. 1

Red Flags Requiring Urgent Evaluation

• New headache onset at age >50 years 2, 1
• Temporal location with tenderness over temporal artery 1
• Associated jaw claudication, visual symptoms, or constitutional symptoms 1, 3
• Elevated ESR warrants immediate high-dose corticosteroids (typically prednisone 60mg daily) and urgent rheumatology/ophthalmology consultation 1

Initial Treatment Algorithm (After Excluding Secondary Causes)

For Mild to Moderate Temporal Headache

Start with oral NSAIDs as first-line therapy: aspirin 650-1000mg, ibuprofen 400-800mg, or naproxen sodium 275-550mg. 2, 4

• NSAIDs have the strongest evidence for efficacy and favorable tolerability 2, 4
• Combination therapy with aspirin + acetaminophen + caffeine is also effective first-line treatment 2, 4
• Acetaminophen alone is ineffective for migraine and should not be used as monotherapy 2

For Moderate to Severe Temporal Headache or Failed NSAID Response

Escalate to triptans as second-line therapy: sumatriptan 50-100mg, rizatriptan, or zolmitriptan orally. 2, 4, 5

• Triptans are most effective when taken early in the attack while headache is still mild 2
• All triptans have well-documented effectiveness; if one fails, try another as response varies 2
• Contraindications include uncontrolled hypertension, cardiovascular disease, basilar or hemiplegic migraine 2

For Temporal Headache with Nausea/Vomiting

Use non-oral routes: subcutaneous sumatriptan 6mg or intranasal sumatriptan 20mg, combined with antiemetic therapy. 2, 4

• Add metoclopramide 10mg IV/oral or prochlorperazine 10-25mg for nausea 2, 4
• Metoclopramide provides synergistic analgesia beyond just treating nausea 2, 4

Critical Pitfalls to Avoid

Limit acute medication use to no more than twice weekly to prevent medication-overuse headache (MOH), which creates a vicious cycle of increasing headache frequency. 2, 4

• Rebound headaches can occur with opioids, triptans, ergotamine, and caffeine/butalbital-containing analgesics 2
• Avoid opioids (meperidine, butorphanol) as they lead to dependency, rebound headaches, and loss of efficacy 2, 4
• If using acute medications more than 2 days per week, initiate preventive therapy 2, 4

When to Consider Rescue Therapy

For severe temporal headache unresponsive to first and second-line treatments:

• Parenteral ketorolac 60mg IM has rapid onset (approximately 6 hours duration) with minimal rebound risk 2, 4
• Intranasal DHE (dihydroergotamine) has good evidence for efficacy and safety 2, 5
• Consider IV metoclopramide 10mg + IV ketorolac 30mg combination for severe attacks 4

Dosing Specifics

NSAIDs (First-Line)

• Aspirin: 650-1000mg every 4-6 hours (max 4g/day) 2
• Ibuprofen: 400-800mg every 6 hours (max 2.4g/day) 2
• Naproxen sodium: 275-550mg every 2-6 hours (max 1.5g/day) 2

Triptans (Second-Line)

• Sumatriptan oral: 50-100mg (may repeat once after 2 hours if needed) 6
• Sumatriptan subcutaneous: 6mg (highest efficacy: 59% pain-free at 2 hours) 4, 6
• Rizatriptan, naratriptan, zolmitriptan: per product labeling 2, 5