What is the appropriate management for a left-sided headache with left retroorbital pain and tenderness on palpation of the left parietal region?

Management of Left-Sided Headache with Retroorbital Pain and Parietal Tenderness

This presentation requires immediate evaluation for cluster headache versus secondary causes, with high-flow oxygen as first-line abortive therapy if cluster headache is confirmed, while ruling out dangerous etiologies through targeted history and examination.

Immediate Diagnostic Considerations

Red Flag Assessment

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

• Obtain neuroimaging (MRI or CT) immediately if any of the following are present: sudden onset "thunderclap" quality, fever, headache worse with Valsalva maneuver or exercise, abnormal neurologic examination, or rapidly increasing frequency/severity 1, 2
• The presence of parietal tenderness on palpation warrants consideration of temporal arteritis (giant cell arteritis), particularly if the patient is over 50 years old, though this typically affects the temporal rather than parietal region 3
• Sphenoidal sinusitis presents with permanent retro-orbital headache radiating to the vertex and requires antibiotic therapy with amoxicillin-clavulanate or fluoroquinolones active against pneumococci 3

Distinguish Between Primary Headache Types

The combination of unilateral retroorbital pain with parietal tenderness creates a diagnostic challenge requiring careful pattern recognition:

Cluster Headache Features (Most Likely Given Presentation):

• Severe unilateral orbital, supraorbital, or temporal pain lasting 15-180 minutes 3, 2
• Attack frequency of one to eight attacks per day during cluster periods 3, 2
• Ipsilateral autonomic features are pathognomonic: lacrimation, nasal congestion, rhinorrhea, forehead/facial sweating, ptosis, miosis, or eyelid edema 3, 2
• Pain is excruciating in intensity, not merely moderate 2

Migraine Features (Less Likely Without Bilateral Component):

• Typically bilateral or alternating-side headache, though can be unilateral 3, 2
• Throbbing character with moderate to severe intensity 3
• Worsening with routine activity 3
• Associated with nausea/vomiting, photophobia, and phonophobia rather than autonomic features 3, 2

Critical Examination Findings:

• Ask specifically about ipsilateral eye tearing, nasal congestion, or facial sweating during attacks—their presence confirms cluster headache over migraine 2
• Palpate the greater occipital nerve at the occipital prominence—tenderness that reproduces the eye pain suggests cervicogenic headache 4
• Palpate the supraorbital notch—tenderness with transitory relief upon nerve blockade indicates supraorbital neuralgia 5

First-Line Abortive Treatment

For Cluster Headache (If Autonomic Features Present)

High-flow oxygen therapy is the gold-standard first-line treatment:

• Administer 12-15 liters per minute via non-rebreather mask for 15-20 minutes 2
• Provides rapid relief within 15 minutes in 70-80% of patients 2
• Has no contraindications and carries no medication overuse risk 2
• Prescribe portable oxygen tanks for home use to enable immediate treatment of attacks 2

Avoid common errors:

• Do not use acetaminophen alone—it is ineffective for cluster headache 2
• Do not routinely use opioids due to dependency risk, rebound headaches, and loss of efficacy 2

For Migraine (If No Autonomic Features)

If the presentation lacks autonomic features and suggests migraine:

• First-line: Naproxen sodium 500-825 mg at onset, can repeat every 2-6 hours (maximum 1.5 g/day) 1
• Alternative first-line: Combination aspirin + acetaminophen + caffeine for moderate-to-severe attacks 1
• Add antiemetic 20-30 minutes before analgesic: metoclopramide 10 mg orally or prochlorperazine 25 mg orally 1

If oral therapy fails due to nausea/vomiting:

• Subcutaneous sumatriptan 6 mg is most rapid and effective (59% pain-free at 2 hours) 1, 6
• Alternative: Intranasal sumatriptan 5-20 mg 1
• Sumatriptan is contraindicated in patients with heart disease, uncontrolled hypertension, hemiplegic/basilar migraine, or peripheral vascular disease 6

Medication-Overuse Headache Prevention

Critical warning for all primary headache types:

• Limit acute treatment to no more than 2 days per week to prevent medication-overuse headache (MOH) 1, 2
• MOH creates a vicious cycle of increasing headache frequency leading to daily headaches 1
• Triptans, ergotamine, opioids, and caffeine-containing analgesics are most likely to cause MOH 1, 2

When Preventive Therapy is Indicated

Consider preventive therapy if:

• Continuous headache of prolonged duration is present 1
• Attacks occur two or more times per month causing significant disability 2
• Acute medication is required more than twice weekly 1, 2

First-line preventive options for migraine:

• Propranolol 80-160 mg daily (long-acting formulation) 1
• Metoprolol 50-100 mg twice daily or 200 mg modified-release once daily 1
• Candesartan 16-32 mg daily 1
• Contraindications: Beta-blockers should not be used in patients with asthma, cardiac failure, atrioventricular block, or depression 1

Evaluate preventive therapy effectiveness at 2-3 months, as oral agents require this duration to demonstrate efficacy 1

Special Diagnostic Considerations

Cervicogenic Headache

• If palpation of the left occipital prominence reveals tenderness in the area of the greater occipital nerve and reproduces the eye pain, consider cervicogenic headache 4
• Confirm diagnosis with greater occipital nerve blockade—symptom resolution is diagnostic 4

Supraorbital Neuralgia

• Characterized by forehead pain in supraorbital nerve territory without side shift 5
• Tenderness on the supraorbital notch or nerve trajectory is diagnostic 5
• Absolute but transitory relief upon supraorbital nerve blockade confirms diagnosis 5

Rare but Important Differentials

• Tolosa-Hunt syndrome: Orbital pain with ophthalmoplegia, elevated ESR, treated with high-dose intravenous methylprednisolone 7
• Ictal epileptic headache: Short-lasting severe retroorbital pain attacks from frontal lobe epilepsy, may require EEG and anti-epileptic drugs 8

Follow-Up Strategy

Re-evaluate within 2-3 months to assess:

• Attack frequency (headache days per month) 1
• Attack severity and pain intensity 1
• Migraine-related disability 1
• Adverse events from medications 1
• Adherence to treatment plan 1
• Use headache calendars to track symptomatic days and acute medication use 1