Sharp Right-Sided Forehead Pain: Diagnostic Approach and Treatment
For sharp, unilateral forehead pain, you must first distinguish between primary headache disorders (migraine, trigeminal neuralgia variants, cluster headache) and secondary causes requiring urgent evaluation, then initiate appropriate acute treatment based on the specific diagnosis.
Immediate Red Flag Assessment
Before treating as a primary headache, exclude dangerous secondary causes by evaluating for 1:
- Thunderclap onset (subarachnoid hemorrhage)
- New neurological deficits (stroke, mass lesion)
- Visual changes, jaw claudication, scalp tenderness in patients >50 years (giant cell arteritis - requires ESR/CRP and temporal artery evaluation) 1
- Fever, neck stiffness (meningitis)
- Recent head trauma
- Progressive worsening pattern
If any red flags present, obtain neuroimaging (MRI preferred) and appropriate laboratory studies immediately 1.
Characterizing the Pain Pattern
Sharp, Brief, Electric Shock-Like Pain (Seconds to 2 Minutes)
This pattern suggests trigeminal neuralgia or its variants 1:
Trigeminal neuralgia: Paroxysmal attacks triggered by light touch (washing face, cold wind, eating, brushing teeth), with refractory periods between attacks 1
- First-line treatment: Carbamazepine remains the primary drug of choice, though oxcarbazepine is equally effective with fewer side effects 1
- Alternative agents include lamotrigine, baclofen, gabapentin with ropivacaine, or pregabalin 1
- Obtain MRI to exclude secondary causes (tumors, multiple sclerosis, vascular compression) 1
SUNA/SUNCT (if accompanied by tearing, red eye, nasal symptoms): Rapid attacks lasting seconds to minutes, up to 200 attacks daily, no refractory period 1
Moderate to Severe Throbbing/Sharp Pain (Hours Duration)
This pattern suggests migraine, particularly if unilateral 1:
For Mild to Moderate Attacks
Start with NSAIDs as first-line therapy 1:
Combination therapy: Aspirin-acetaminophen-caffeine has strong evidence for efficacy 1
For Moderate to Severe Attacks or NSAID Failure
Add a triptan to an NSAID or acetaminophen 1:
- Recommended triptans: Eletriptan, frovatriptan, rizatriptan, sumatriptan (oral or subcutaneous), sumatriptan-naproxen combination, or zolmitriptan (oral or intranasal) 1
- Take early when headache is still mild for maximum effectiveness 1
- If one triptan fails, try another - individual responses vary 1
For Triptan Failures or Contraindications
Consider CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant 1
Lasmiditan (ditan) may be used when all other treatments fail, though it causes temporary driving impairment 1
Severe, Intractable Pain Requiring Emergency Treatment
For severe migraine requiring IV therapy 2:
- First-line IV protocol: Metoclopramide 10 mg IV plus ketorolac 30 mg IV 2
- Alternative: Prochlorperazine 10 mg IV (equally effective as metoclopramide) 1, 2
- Ketorolac provides rapid onset with 6-hour duration and minimal rebound risk 1, 2
Avoid opioids - they lead to dependency, rebound headaches, and loss of efficacy 1, 2
Avoid butalbital-containing compounds - high risk of medication-overuse headache 1, 2
Cluster Headache Consideration
If pain is severe, strictly unilateral, periorbital/temporal with autonomic features (tearing, nasal congestion, ptosis), consider cluster headache 1:
- Acute treatment: Subcutaneous sumatriptan 6 mg or intranasal zolmitriptan 10 mg 1
- Normobaric oxygen therapy is also effective 1
Critical Medication Overuse Warning
Limit acute therapy to no more than 2 days per week to prevent medication-overuse headache 1, 2:
- Risk threshold: ≥15 days/month with NSAIDs; ≥10 days/month with triptans 1
- If requiring treatment >2 days weekly, initiate preventive therapy rather than increasing acute medication frequency 2
When Preventive Therapy Is Indicated
Start preventive therapy if 1, 2:
- Two or more attacks per month producing disability lasting ≥3 days
- Acute treatments fail or are contraindicated
- Using abortive medication more than twice weekly
- At risk for medication-overuse headache
Preventive options with strongest evidence 1:
- Candesartan or telmisartan (strong recommendation) 1
- CGRP monoclonal antibodies: erenumab, fremanezumab, galcanezumab (strong recommendation) 1
- Topiramate, propranolol, or valproate (weak recommendations) 1
Sinus Disease Consideration
Facial pain alone is rarely caused by chronic rhinosinusitis 1:
- If no other nasal symptoms (congestion, discharge, olfactory dysfunction) or examination abnormalities, do not attribute to sinuses 1
- True rhinogenic facial pain improves when other CRS symptoms improve with medical treatment 1
- Consider primary headache disorder (especially migraine) or medication overuse headache if patient has been using analgesics frequently 1