What are the treatment options for left-sided head pressure and vomiting?

Evaluation and Treatment of Left-Sided Head Pressure and Vomiting

Left-sided head pressure with vomiting requires immediate assessment for red flag features suggesting secondary headache (intracranial pathology, meningitis, or subarachnoid hemorrhage), followed by treatment with NSAIDs plus antiemetics for presumed migraine if no alarm features are present. 1

Immediate Red Flag Assessment

Before initiating treatment, you must actively exclude these alarm features that mandate urgent neuroimaging and specialist evaluation:

• Sudden onset "thunderclap" headache (suggests subarachnoid hemorrhage) 1
• Fever with neck stiffness (suggests meningitis) 1
• Focal neurological deficits (weakness, sensory changes, visual field defects) 1
• Altered consciousness or personality changes 1
• Headache brought on by coughing, sneezing, or Valsalva maneuvers (suggests space-occupying lesion) 1
• Age >50 years with new-onset headache (consider temporal arteritis) 1
• Progressive worsening over days to weeks 1

If any red flags are present, obtain CT head immediately and consult neurology/neurosurgery before treating symptomatically. 1

First-Line Treatment for Presumed Migraine

If no red flags are present, initiate combination therapy with NSAIDs plus prokinetic antiemetics immediately:

Acute Medication Regimen

• NSAIDs as primary therapy: Ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 900-1000 mg 1, 2
• Prokinetic antiemetic for vomiting: Metoclopramide 10 mg IV/PO or prochlorperazine 10 mg IV 1, 2
  • These agents provide dual benefit: control nausea/vomiting AND provide synergistic analgesia for migraine pain 2
  • Administer 20-30 minutes before NSAID when possible for optimal effect 2

Critical Timing Consideration

Administer medications early in the attack while pain is still mild to maximize effectiveness. 1 Delayed treatment significantly reduces efficacy of all acute migraine medications. 2

Second-Line Treatment if NSAIDs Fail

If NSAIDs provide inadequate relief after 2-3 migraine episodes, escalate to triptans:

• Oral triptans: Sumatriptan 50-100 mg, rizatriptan 10 mg, or zolmitriptan 2.5-5 mg 1, 2
• For severe vomiting: Subcutaneous sumatriptan 6 mg (59% complete pain relief at 2 hours) or intranasal sumatriptan 20 mg 1, 2
• Contraindications: Uncontrolled hypertension, coronary artery disease, basilar or hemiplegic migraine 1

Consider combining triptans with fast-acting NSAIDs to prevent recurrence, as 40% of patients experience symptom return within 48 hours. 1, 2

Medications to Avoid

Never use these agents for acute migraine treatment:

• Opioids (questionable efficacy, high dependency risk, cause medication-overuse headache) 1, 2
• Barbiturates (butalbital-containing compounds cause rebound headaches) 1
• Oral ergot alkaloids (poorly effective and potentially toxic) 1

Alternative Antiemetic Options

If metoclopramide or prochlorperazine are contraindicated or unavailable:

• Ondansetron 8 mg IV/PO is effective for nausea without sedation or akathisia risk 3, 4
• However, ondansetron lacks the synergistic analgesic benefit of dopamine antagonists for migraine pain 2, 3

Critical Medication-Overuse Headache Prevention

Limit all acute medications to no more than 2 days per week to prevent medication-overuse headache (MOH), which causes transformation to daily headaches. 1, 2 If the patient requires acute treatment more frequently, initiate preventive therapy immediately (propranolol 80-240 mg daily, amitriptyline 30-150 mg daily, or divalproex sodium 500-1500 mg daily). 1

When Current Medication Stops Working

If previously effective medications fail:

1. Rule out medication-overuse headache first (using acute meds >2 days/week) 2
2. Try a different triptan - failure of one does not predict failure of others 2
3. Ensure early administration - triptans only work when taken while pain is mild 2
4. Add combination therapy with NSAIDs to prevent relapse 2
5. Initiate preventive therapy if attacks continue to impair quality of life despite optimized acute treatment 1, 2

Special Consideration: Spontaneous Intracranial Hypotension

If the patient describes orthostatic headache (worse when upright, better when lying flat) with vomiting, consider spontaneous intracranial hypotension from CSF leak. 1, 5 This requires brain MRI with contrast and specialist referral, as treatment differs fundamentally from migraine (epidural blood patch rather than analgesics). 1