What should I do for left ear pain and a throbbing headache lasting 2 days?

Left Ear Pain and Throbbing Headache for 2 Days

You need immediate pain management with analgesics (NSAIDs like ibuprofen or naproxen) while simultaneously evaluating whether this is primary ear disease (acute otitis externa), a migraine with ear pain, or a more serious secondary headache requiring urgent evaluation. 1

Immediate Assessment Priority

Your first task is to determine if this represents:

• Primary ear pathology causing referred headache
• Primary headache disorder (migraine) with referred ear pain
• Secondary headache requiring urgent intervention

Critical Red Flags to Rule Out First

Examine for these warning signs that mandate immediate imaging or emergency referral 2, 3:

• Fever or constitutional symptoms (suggests infection, meningitis)
• Neurologic deficits on examination
• Sudden onset "thunderclap" pattern
• Headache worsened by Valsalva maneuver or awakening from sleep
• Age >50 years with new-onset headache
• History of cancer, HIV, or immunosuppression

Ear Examination Findings Guide Next Steps

If Ear Canal Shows Inflammation (Acute Otitis Externa)

Tragal tenderness is the key distinguishing feature - if present with ear canal edema, erythema, or discharge, this is acute otitis externa 4, 1, 5:

• Prescribe topical antibiotic drops (fluoroquinolone or aminoglycoside with steroid) targeting Pseudomonas aeruginosa and Staphylococcus aureus 4, 1
• Do NOT prescribe systemic antibiotics for uncomplicated cases 4, 1
• Prescribe analgesics immediately - pain relief is the priority and should be addressed regardless of antibiotic therapy 1
• Expect improvement within 48-72 hours; reassess if no response 4

If Ear Examination is Normal

This suggests the headache is primary and the ear pain is referred 6. The throbbing quality strongly suggests migraine 4, 7:

For Moderate to Severe Throbbing Headache:

Treat immediately with combination therapy: triptan (sumatriptan, rizatriptan, or eletriptan) PLUS NSAID (ibuprofen or naproxen) or acetaminophen 4:

• This combination is more effective than either agent alone
• Begin treatment as soon as possible after onset for best efficacy 4
• Add an antiemetic with prokinetic properties (metoclopramide or prochlorperazine) if nausea present 4

For Mild to Moderate Headache:

Start with NSAID alone or NSAID plus acetaminophen 4:

• Aspirin, ibuprofen, or naproxen are appropriate first-line options
• Combination of aspirin + acetaminophen + caffeine is effective 4

Critical Medication Overuse Warning

Limit acute medication use to prevent medication overuse headache 4:

• NSAIDs: maximum 15 days per month
• Triptans: maximum 10 days per month
• If using acute medications more frequently, preventive therapy is needed 4

When to Reassess or Refer

Reassess within 48-72 hours if no improvement 4, 3:

• For ear pathology: consider aural toilet, wick placement, or culture if not responding 4
• For headache: reconsider diagnosis, evaluate for secondary causes, or refer to neurology 3
• If symptoms persist beyond 7-14 days despite appropriate therapy, specialist referral is warranted 4, 3

Common Pitfalls to Avoid

• Failing to provide adequate analgesia in the first 24-48 hours - pain control is the immediate priority regardless of underlying cause 1
• Prescribing systemic antibiotics for uncomplicated ear canal inflammation when topical therapy is superior 4, 1
• Using opioids for migraine treatment - they are ineffective and should be avoided 4
• Missing temporomandibular joint syndrome as a cause of referred ear pain, especially if jaw tenderness or clicking present 1
• Attributing persistent symptoms to benign causes without adequate workup in high-risk patients (age >50, tobacco/alcohol use, diabetes) 1, 6