What is the management approach for a patient with a unilateral pulsatile temporal headache and normal blood pressure?

Management of Unilateral Pulsatile Temporal Headache with Normal Blood Pressure

This presentation is consistent with migraine without aura, and you should initiate acute treatment with NSAIDs or acetaminophen as first-line therapy, escalating to triptans if these fail, while simultaneously ruling out giant cell arteritis if the patient is over 50 years old. 1, 2

Immediate Diagnostic Considerations

The unilateral pulsatile temporal location strongly suggests migraine, which characteristically presents with unilateral, pulsating quality pain as one of its defining features. 1, 2 However, the temporal location requires careful consideration of giant cell arteritis, particularly in specific patient populations.

Age-Based Risk Stratification

• If patient is ≥50 years old: Giant cell arteritis becomes a critical differential diagnosis requiring urgent evaluation with ESR/CRP and potential rheumatology referral, as this condition can cause new-onset headache with scalp tenderness and jaw claudication. 2, 3
• If patient is <50 years old: Giant cell arteritis is effectively ruled out, and primary headache disorders become the focus. 2, 4

Red Flag Assessment

Evaluate immediately for the following features that would mandate urgent imaging or specialist referral: 2, 5

• Thunderclap onset (instantly peaking pain suggesting subarachnoid hemorrhage)
• Focal neurological deficits (suggesting stroke, mass lesion, or cerebrovascular event)
• Fever with neck stiffness (suggesting meningitis)
• Progressive worsening or headache awakening patient from sleep (suggesting increased intracranial pressure or mass lesion)
• Recent head trauma
• Altered consciousness or personality changes

The normal blood pressure (108/64) effectively rules out hypertensive emergency as a cause. 2

Establishing Migraine Diagnosis

To confirm migraine without aura, verify the patient meets ICHD-3 criteria: 1, 2

Required Features (Must Have All):

• At least 5 lifetime attacks lasting 4-72 hours when untreated
• At least 2 pain characteristics: unilateral location (✓ present), pulsating quality (✓ present), moderate-to-severe intensity, or aggravation by routine physical activity
• At least 1 associated symptom: nausea/vomiting OR both photophobia and phonophobia

Differentiating from Other Conditions

Cluster headache is excluded if the patient lacks: 4

• Strictly unilateral severe orbital/periorbital pain lasting only 15-180 minutes (not 4-72 hours)
• Ipsilateral autonomic symptoms (lacrimation, conjunctival injection, nasal congestion, ptosis)
• Restlessness or agitation during attacks (migraine patients prefer to lie still)

Tension-type headache is excluded if the pain is: 2

• Unilateral rather than bilateral
• Pulsating rather than pressing/tightening
• Associated with nausea/vomiting or photophobia/phonophobia

Acute Treatment Algorithm

First-Line Therapy

Initiate NSAIDs (ibuprofen, naproxen) or acetaminophen for mild-to-moderate attacks, limiting use to ≤2 days per week or maximum 10 days per month to prevent medication-overuse headache. 1, 2, 6

Second-Line Therapy

If NSAIDs fail or pain is moderate-to-severe, prescribe triptans (sumatriptan, rizatriptan, or other 5-HT1B/D agonists), which eliminate pain in 20-30% of patients by 2 hours. 2, 7, 6

Critical Triptan Precautions:

• Contraindicated in patients with coronary artery disease, Prinzmetal's angina, uncontrolled hypertension, stroke/TIA history, or Wolff-Parkinson-White syndrome 7
• For patients with multiple cardiovascular risk factors (increased age, diabetes, hypertension, smoking, obesity, strong family history of CAD), perform cardiovascular evaluation before prescribing and consider administering first dose in medically supervised setting with ECG monitoring 7
• Common adverse effects include transient flushing, tightness, or tingling in upper body in 25% of patients 6

Third-Line Alternatives

If triptans are contraindicated or ineffective, consider gepants (rimegepant, ubrogepant), which eliminate headache in 20% of patients at 2 hours with adverse effects of nausea and dry mouth in 1-4% of patients. 6

Lasmiditan (5-HT1F agonist) is safe in patients with cardiovascular risk factors when triptans are contraindicated. 6

Adjunctive Treatment

Add antiemetic with prokinetic properties if nausea/vomiting is present. 1

Medication-Overuse Headache Prevention

Critical pitfall: Regular overuse of non-opioid analgesics on ≥15 days/month for ≥3 months, or any other acute medication on ≥10 days/month for ≥3 months, causes medication-overuse headache, which presents as daily headaches or marked increase in migraine frequency. 1, 2

• Never prescribe opioids for headache 1
• Counsel patients to limit acute medication use to prevent this complication 1, 2

When to Consider Preventive Therapy

Initiate preventive medications if: 1, 2

• Attacks occur frequently enough to impair quality of life
• Acute treatments are ineffective or contraindicated
• Patient is at risk for medication-overuse headache

Preventive options include antihypertensives (propranolol), antiepileptics, antidepressants, CGRP monoclonal antibodies, or onabotulinumtoxinA, which reduce migraine by 1-3 days per month relative to placebo. 6, 8

Referral Indications

Emergency admission required if: 2

• Any red flag present
• Patient unable to self-care without help

Urgent neurology referral (within 48 hours) if: 2

• Suspected spontaneous intracranial hypotension (orthostatic headache pattern)

Routine neurology referral (2-4 weeks) if: 2

• Diagnosis uncertain after initial evaluation
• First-line treatments fail
• Suspected primary headache disorder requiring specialist management

Diagnostic Workup

Headache diary: Document frequency, duration, character, triggers, accompanying symptoms, and medication use to increase diagnostic accuracy and reduce recall bias. 2

Neuroimaging is NOT routinely indicated for typical migraine presentation without red flags. 2, 5

MRI brain with and without contrast is preferred if imaging is needed for subacute presentations or suspected tumor/inflammatory process. 2

ESR/CRP testing is mandatory if patient is ≥50 years old with new-onset headache to evaluate for giant cell arteritis, though note that ESR can be normal in 10-36% of giant cell arteritis cases. 2