What are the treatment options for a 48-year-old female with a 4-day constant pulsating headache, primarily located on the top of the head and left orbital area, who experiences mild blurry vision and relief with rest, but worsens with activity?

Treatment Recommendations for Migraine Headache

For this 48-year-old woman with a 4-day constant pulsating headache with orbital involvement and mild visual symptoms, I recommend starting with combination therapy of an NSAID (ibuprofen 400-600mg or naproxen 500mg) plus acetaminophen 1000mg plus caffeine, taken as early as possible, along with rest in a dark, quiet room. 1, 2

Pharmacologic Treatment Strategy

First-Line Medication Options

• NSAIDs are the recommended first-line treatment for this presentation, with strong evidence supporting ibuprofen, naproxen sodium, and aspirin 3, 1, 2
• Combination therapy with acetaminophen, aspirin, and caffeine is more effective than acetaminophen alone, which has not been shown to be beneficial as monotherapy for migraine 3, 1
• The combination provides synergistic analgesia, with caffeine enhancing absorption and efficacy of the analgesics 1

Important Timing Consideration

• Administer medication as early as possible during the attack to improve efficacy - the 4-day duration suggests delayed treatment, which reduces effectiveness 3, 1, 2
• Early treatment is critical because medications work best when taken while headache is still mild 4

When to Escalate Beyond NSAIDs

If NSAIDs and combination analgesics fail after 2-3 headache episodes, escalate to:

• Triptans (sumatriptan, rizatriptan, or naratriptan) for moderate to severe migraine that doesn't respond to simple analgesics 3, 1, 2
• Rizatriptan has faster onset (60-90 minutes to peak) and comes in absorbable wafer form, beneficial if nausea develops 4
• Triptans are contraindicated in uncontrolled hypertension, ischemic vascular disease, and hemiplegic migraine 4, 5

Non-Pharmacologic Treatment Options

Immediate Environmental Modifications

• Rest in a dark, quiet room - this directly addresses photophobia and phonophobia that accompany migraine 3
• Sleep or rest in a recumbent position - the patient already reports improvement with lying down, which should be encouraged 3
• Avoid physical activity during the attack, as movement worsens migraine symptoms 3

Additional Non-Medication Strategies

• Apply cold compresses or ice packs to the head and neck - particularly to the left frontal/orbital area where pain is localized 3
• Maintain adequate hydration - dehydration can worsen migraine symptoms 3
• Avoid known migraine triggers including bright lights, loud noises, strong odors, and certain foods 3

Adjunctive Measures for Nausea

• Caffeine serves dual purposes - it provides synergistic analgesia and can help with associated symptoms 1
• If nausea develops, consider adding ginger tea or acupressure at the P6 point (inner wrist) as non-pharmacologic options 3

Critical Medication Overuse Warning

• Limit acute treatment to no more than 2 days per week to prevent medication-overuse headache, which can lead to daily chronic headaches 1, 2, 4
• The 4-day constant headache raises concern - if this pattern continues or headaches occur more than twice weekly, preventive therapy should be initiated rather than increasing acute medication frequency 1, 4

Red Flag Reassessment

While you've ruled out immediate red flags, the following warrant continued monitoring:

• Progressively worsening headache over 4 days - if this continues beyond 5-7 days despite treatment, consider neuroimaging 3
• New-onset headache in a 48-year-old - while not elderly, this is later onset than typical migraine (usually begins in 20s-30s) 3
• Headache worsened by Valsalva maneuver or movement - your patient reports worsening with activity, which fits migraine but also warrants close follow-up 3

When to Seek Urgent Care

If the patient fails outpatient management, IV combination therapy with metoclopramide 10mg plus ketorolac 30mg is the most effective urgent care treatment, avoiding opioids which lead to dependency and rebound headaches 1, 4

Common Pitfall to Avoid

Do not allow the patient to increase frequency of acute medication use in response to this prolonged attack - this creates medication-overuse headache. Instead, if headaches persist or recur frequently, transition to preventive therapy while optimizing the acute treatment strategy 1, 4