What should I do for a throbbing headache lasting 3 days?

Management of a 3-Day Throbbing Headache

For a throbbing headache lasting 3 days, you should first rule out secondary causes with focused history and examination for red flags, then treat as likely migraine with NSAIDs (ibuprofen 400-800mg or naproxen 500-825mg) combined with an antiemetic if nausea is present, and consider a triptan if NSAIDs fail within 2 hours. 1

Immediate Assessment for Red Flags

Before treating as a primary headache disorder, you must evaluate for secondary causes that require urgent intervention 1:

• Sudden onset ("thunderclap" - maximum intensity within 1 minute) suggests subarachnoid hemorrhage 2
• New onset age ≥50 years increases risk of secondary causes 1
• Neurological deficits on examination (weakness, vision changes, altered mental status) 1
• Fever with neck stiffness suggests meningitis 1
• History of cancer or immunosuppression 3
• Worsening pattern or change in headache character 1

If any red flags are present, neuroimaging (CT head) and potentially lumbar puncture are indicated before symptomatic treatment 4, 2.

Diagnostic Considerations

A 3-day throbbing headache most likely represents migraine without aura if it meets these criteria 1:

• Duration: 4-72 hours when untreated 1
• At least two of: unilateral location, pulsating quality, moderate-to-severe intensity, aggravation by routine activity 1
• At least one of: nausea/vomiting, photophobia and phonophobia 1

The 3-day duration suggests this may be approaching status migrainosus (severe continuous migraine lasting up to one week), which may require more aggressive treatment 1.

First-Line Acute Treatment

For Moderate-to-Severe Throbbing Headache:

Start with NSAIDs as first-line therapy 1:

• Ibuprofen 400-800mg orally, can repeat every 6 hours (maximum 2.4g/day) 1
• Naproxen sodium 500-825mg orally, can repeat every 2-6 hours (maximum 1.5g/day) 1
• Aspirin 650-1000mg orally every 4-6 hours (maximum 4g/day) 1

Add an antiemetic 20-30 minutes before or with the NSAID for synergistic analgesia 1:

• Metoclopramide 10mg orally or IV 1
• Prochlorperazine 10mg orally or IV 1

If NSAIDs Fail After 2 Hours:

Escalate to triptan therapy 1, 5:

• Sumatriptan 50-100mg orally (most evidence-based) 1, 6
• Rizatriptan, naratriptan, or zolmitriptan are alternatives 1
• Can repeat dose after 2 hours if headache returns (maximum 200mg sumatriptan in 24 hours) 6

Triptans achieve pain-free response in 20-30% of patients by 2 hours but may cause transient flushing, tightness, or tingling in 25% of patients 3.

Alternative Routes for Severe Nausea/Vomiting

If significant nausea or vomiting is present early in the attack, use non-oral routes 1:

• Subcutaneous sumatriptan 6mg (most effective route - 59% pain-free by 2 hours) 5, 7, 6
• Intranasal sumatriptan 5-20mg 5
• Ketorolac 60mg IM (parenteral NSAID with rapid onset) 1

Treatment for Status Migrainosus (3+ Days)

For a severe migraine lasting 3 days that hasn't responded to initial treatment, consider systemic corticosteroids 1, 7:

• Corticosteroids are the treatment of choice for status migrainosus 7
• However, evidence for acute migraine attacks is limited 1

Critical Medication Overuse Warning

Limit acute medication use to no more than 2 days per week to prevent medication-overuse headache 1, 5:

• Using acute medications (NSAIDs ≥15 days/month or triptans ≥10 days/month for >3 months) can cause rebound headaches 1
• This creates a cycle of increasing headache frequency 1

When to Consider Preventive Therapy

Initiate preventive therapy if 1:

• ≥2 attacks per month producing disability lasting ≥3 days 1
• Using acute medications more than twice weekly 1
• Acute treatments are contraindicated or ineffective 1

First-line preventive options include 1:

• Propranolol 80-240mg/day 1
• Topiramate 50-100mg/day (only agent proven in chronic migraine) 1
• Amitriptyline 30-150mg/day 1

Contraindications to Triptans

Do not use triptans if patient has 6:

• Ischemic heart disease or cardiovascular risk factors 6, 3
• Uncontrolled hypertension 6
• Hemiplegic or basilar migraine 6
• Recent use (within 24 hours) of ergotamines or other triptans 6

Follow-Up and Referral

Arrange follow-up within 2-3 months to evaluate treatment response 1. If headaches persist despite optimized acute treatment, referral to a headache specialist or neurology is indicated 1.