What are the possible causes and treatments for a headache behind the right ear, forehead, and pressure around the eyes?

Headache Behind Right Ear, Forehead, and Pressure Around Eyes

Most Likely Diagnosis

Your symptom pattern—unilateral pain behind the ear combined with frontal and periorbital pressure—suggests either migraine (possibly with tension-type features) or a secondary headache that requires evaluation for red flags. 1, 2

Immediate Red Flag Assessment

You need urgent evaluation if any of these are present:

• Abrupt onset ("thunderclap" quality) 3, 2
• Age over 50 with new or changed headache pattern 4, 3
• Neurologic symptoms (vision changes, weakness, coordination problems, confusion) 3, 2
• Fever with neck stiffness (suggests meningitis) 3
• Headache worsened by Valsalva, cough, or exertion 3
• Progressive worsening over days to weeks 1, 3
• History of cancer or immunosuppression 3, 2

If any red flags are present, neuroimaging (MRI preferred) is indicated immediately. 4, 3

Specific Diagnostic Considerations for Your Pattern

Migraine Features to Assess

Your combination of unilateral (behind right ear) and bilateral (forehead/eyes) pain is consistent with migraine, which can present with:

• Moderate to severe intensity 1
• Throbbing or pulsating quality 1, 2
• Worsening with routine physical activity 1
• Associated nausea, photophobia, or phonophobia 1, 2
• Duration of 4-72 hours if untreated 1

Tension-Type Features

Pressure around eyes and forehead suggests possible tension-type component:

• Bilateral, band-like tightness from forehead to occiput 5
• Pressing or tightening (non-pulsatile) quality 1, 5
• Mild to moderate intensity 1, 5
• No nausea or vomiting (though anorexia possible) 1, 5

Morning Headache Considerations

If this occurs predominantly upon waking:

• Obstructive sleep apnea causes morning headaches that resolve within hours of waking 4
• Increased intracranial pressure causes headaches worse when lying flat, improving upright 4
• Medication overuse headache if you're taking analgesics more than 2 days per week 4

Acute Treatment Algorithm

First-Line Treatment (Mild to Moderate Pain)

Start with NSAIDs immediately at headache onset while pain is still mild:

• Naproxen sodium 500-825 mg at onset, repeat every 2-6 hours as needed (maximum 1.5 g/day) 6
• Ibuprofen 400-800 mg at onset 6
• Aspirin 1000 mg at onset 6

Critical limitation: Use NSAIDs no more than 2 days per week to prevent medication-overuse headache. 6

Add Antiemetic for Synergistic Effect

Even without nausea, antiemetics provide direct analgesic benefit:

• Metoclopramide 10 mg orally, 20-30 minutes before NSAID 6
• Prochlorperazine 25 mg orally as alternative 6

Second-Line Treatment (Moderate to Severe Pain)

If NSAIDs fail after 2-3 episodes, escalate to triptans:

• Sumatriptan 50-100 mg orally at onset 6
• Rizatriptan 10 mg orally at onset 6
• Naratriptan 2.5 mg orally at onset 6

Contraindications: Avoid triptans if you have cardiovascular disease, uncontrolled hypertension, or previous myocardial infarction. 6, 2

Combination Therapy Option

For attacks responding poorly to single agents:

• Aspirin 250 mg + acetaminophen 250 mg + caffeine 65 mg (available as over-the-counter combination) 6

When to Seek Emergency Care

Go to urgent care or emergency department for IV treatment if:

• Severe pain unresponsive to oral medications 6
• Significant nausea/vomiting preventing oral intake 6
• Neurologic symptoms develop 3, 2

Effective IV combination: Metoclopramide 10 mg IV + ketorolac 30 mg IV provides rapid relief. 6

Critical Pitfall to Avoid

Do not use acute medications more than 2 days per week. Frequent use (>2 days/week) causes medication-overuse headache, creating a vicious cycle of daily headaches requiring more medication. 1, 6 This applies to:

• Simple analgesics (acetaminophen, NSAIDs) used >15 days/month 1
• Triptans, combination analgesics, or opioids used >10 days/month 1

When Preventive Therapy Is Needed

You need preventive medication if:

• Headaches occur more than 2 days per week 6
• Acute treatments are ineffective after adequate trials 6
• Quality of life is significantly impaired 1

Preventive options include topiramate, beta-blockers (propranolol), or CGRP monoclonal antibodies, requiring 2-3 months to assess efficacy. 1, 6

Specific Evaluation for Your Pattern

Given the unilateral location behind the ear combined with frontal/periorbital pressure:

• Rule out medication overuse by documenting all over-the-counter and prescription analgesic use 4
• Consider sleep apnea screening if headaches are worse in morning, especially with snoring, obesity, or daytime fatigue 4
• Neuroimaging (MRI brain) indicated if: age >50, new or changed pattern, or any neurologic symptoms 4, 3