Management of Unilateral Headache with Tearing, Throbbing, and Stabbing Pain
Critical Diagnostic Clarification
Your symptom description—unilateral headache with tearing—suggests cluster headache rather than migraine, which fundamentally changes management. Cluster headaches present with severe unilateral pain accompanied by ipsilateral autonomic features (tearing, nasal congestion, ptosis), while migraine typically presents with throbbing pain, nausea, photophobia, and phonophobia without prominent tearing 1.
However, I will address both possibilities since the distinction is crucial:
If This Is Cluster Headache (Unilateral + Tearing)
Acute Treatment
- High-flow oxygen (12-15 L/min via non-rebreather mask for 15-20 minutes) is first-line treatment for cluster headache attacks 1
- Subcutaneous sumatriptan 6 mg provides the most rapid relief, with 59% achieving complete pain relief by 2 hours 2, 3
- Intranasal sumatriptan (5-20 mg) or zolmitriptan can be used as alternatives 2
Foods to Avoid
- Alcohol is the most important trigger to avoid during cluster periods, as it reliably precipitates attacks within 30-60 minutes 1
- Nitrate-containing foods (processed meats, aged cheeses) should be avoided 1
If This Is Migraine (Without Prominent Tearing)
First-Line Acute Treatment for Mild-to-Moderate Attacks
NSAIDs are the drug of choice for initial migraine treatment, with ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 900-1000 mg being most effective 1.
- Take medication early when pain is still mild to maximize efficacy—early treatment with sumatriptan while pain is mild produces 67% pain-free rates at 2 hours versus only 36% when treating moderate/severe pain 4
- Combination therapy with aspirin 250 mg + acetaminophen 250 mg + caffeine 65 mg provides synergistic analgesia when NSAIDs alone are insufficient 1, 2
- Add metoclopramide 10 mg or prochlorperazine 10-25 mg for nausea, which also provides direct analgesic effects 2
Second-Line Treatment for Moderate-to-Severe Attacks
If NSAIDs fail after 2-3 attacks, escalate to triptans as second-line therapy 1:
- Oral sumatriptan 50-100 mg is the most studied triptan with proven efficacy 1, 3
- Alternative triptans include rizatriptan 10 mg, naratriptan 2.5 mg, or zolmitriptan 2.5-5 mg 1, 2
- If one triptan fails, try another—failure of one does not predict failure of others 1, 2
- For rapid-onset severe attacks or vomiting: subcutaneous sumatriptan 6 mg provides fastest relief (70-80% response within 1 hour) 1, 5
Third-Line Treatment
If all triptans fail after adequate trials (no response in at least 3 consecutive attacks):
- Consider lasmiditan, ubrogepant, or rimegepant (gepants/ditans), though availability is limited 1, 2
- Intranasal dihydroergotamine (DHE) has good evidence for efficacy and safety 1
Critical Medication Overuse Prevention
Limit acute medication use to no more than 2 days per week to prevent medication-overuse headache 1, 2:
- NSAIDs: <15 days/month 6
- Triptans: <10 days/month 6
- If using acute medications more frequently, initiate preventive therapy immediately 1, 2
Foods and Triggers to Avoid
Common dietary triggers to avoid 1:
- Alcohol (especially red wine)
- Aged cheeses (contain tyramine)
- Processed meats (contain nitrates/nitrites)
- Caffeine withdrawal (maintain consistent intake or avoid entirely)
- Chocolate
- Monosodium glutamate (MSG)
- Artificial sweeteners (aspartame)
Non-dietary triggers to address 1:
- Irregular sleep patterns
- Skipping meals
- Stress
- Bright or flickering lights
- Strong odors/perfumes
When to Initiate Preventive Therapy
Start preventive medication if 1, 2:
- Attacks occur ≥2 times per month causing ≥3 days of disability
- Acute medication use exceeds 2 days per week
- Attacks cause significant quality-of-life impairment despite optimized acute treatment
Contraindications and Red Flags
Triptans are contraindicated in 1, 3:
- Uncontrolled hypertension
- Coronary artery disease or risk factors without cardiac evaluation
- Basilar or hemiplegic migraine
- History of stroke or TIA
- Peripheral vascular disease
Seek emergency evaluation if 1:
- Thunderclap headache (subarachnoid hemorrhage)
- Headache with fever and neck stiffness (meningitis)
- New headache pattern in patient >50 years (temporal arteritis)
- Progressive worsening despite treatment
Practical Treatment Algorithm
- At headache onset (mild pain): Take NSAID (ibuprofen 600-800 mg or naproxen sodium 500-825 mg) 1, 2
- If inadequate response after 2 hours: May repeat NSAID dose once 2
- If NSAID fails in 2-3 attacks: Switch to triptan (sumatriptan 50-100 mg) for subsequent attacks 1
- If headache recurs within 24 hours: May take second triptan dose after 2 hours, but this increases medication-overuse risk 1
- If using acute medications >2 days/week: Initiate preventive therapy 2, 6