What are the treatment options for headaches that span from temple to temple?

Treatment of Temple-to-Temple Headaches

For temple-to-temple headaches consistent with migraine, start with NSAIDs (ibuprofen 400-800mg, naproxen 500-825mg, or aspirin 1000mg) as first-line therapy for mild to moderate attacks, and escalate to triptans for moderate to severe attacks or when NSAIDs fail within 2 hours. 1

First-Line Treatment Algorithm

For mild to moderate headaches:

• Start with NSAIDs: ibuprofen 400-800mg, naproxen sodium 500-825mg, or aspirin 650-1000mg 2, 1, 3
• Consider combination therapy with acetaminophen + aspirin + caffeine, which shows superior efficacy to single agents 2, 3
• Administer as early as possible during the attack to improve efficacy 2

For moderate to severe headaches:

• Triptans (sumatriptan 50-100mg, rizatriptan, naratriptan, or zolmitriptan) are first-line therapy and most effective when taken early while headache is still mild 2, 1, 3
• The combination of triptan + NSAID (e.g., sumatriptan 50-100mg PLUS naproxen sodium 500mg) is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 1
• If oral medications are ineffective or the patient rapidly reaches peak intensity, use subcutaneous sumatriptan 6mg, which provides pain relief in 70-82% of patients within 15 minutes 1

Adjunctive Therapy

When nausea or vomiting is present:

• Add metoclopramide 10mg (oral or IV), which provides both antiemetic effects and direct analgesic benefit through central dopamine receptor antagonism 2, 1, 3
• Alternatively, use prochlorperazine 10mg IV or 25mg oral/suppository, which relieves both nausea and headache pain directly 2, 1, 3
• Consider non-oral routes (subcutaneous, intranasal, or IV) when significant nausea prevents oral medication absorption 2

Critical Frequency Limitation

Limit all acute migraine medications to no more than 2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches 2, 1. If the patient requires acute treatment more than twice weekly, initiate preventive therapy immediately 2, 1.

Second-Line and Rescue Options

If first-line treatments fail:

• Intranasal dihydroergotamine (DHE) has good evidence for efficacy and safety as monotherapy 2, 1
• For severe attacks in emergency settings, use IV metoclopramide 10mg PLUS IV ketorolac 30mg, which provides rapid pain relief with minimal rebound headache risk 1
• Avoid opioids (including butorphanol) except when other medications cannot be used, sedation is not a concern, and abuse risk has been addressed, as they lead to dependency and rebound headaches 2, 1

Preventive Therapy Indications

Initiate preventive therapy if:

• The patient has more than 2 headaches per week 2
• Headaches produce disability lasting 3 or more days per month 1
• The patient uses abortive medication more than twice weekly 2, 1

First-line preventive options include:

• Propranolol 80-240mg/day (FDA-approved for migraine prophylaxis) 1, 4
• Topiramate (particularly beneficial for patients with obesity due to weight loss effects) 2, 1
• Amitriptyline 30-150mg/day (especially for mixed migraine and tension-type headache) 1

Important Contraindications

Triptans are contraindicated in:

• Patients with ischemic heart disease, vasospastic coronary disease, or uncontrolled hypertension 2, 1, 3
• Basilar or hemiplegic migraine 2

Common Pitfalls to Avoid

• Do not allow patients to increase frequency of acute medication use in response to treatment failure—this creates a vicious cycle of medication-overuse headache; instead, transition to preventive therapy 1
• Do not prescribe rescue medications containing opioids or butalbital for routine home use, as these carry high risks of dependency and rebound headaches 2, 1
• Do not assume all triptans are equivalent—if one triptan fails, try a different one, as failure of one does not predict failure of others 1
• Monitor total daily acetaminophen intake to ensure it does not exceed 4000mg per day from all sources 1

When to Consider Alternative Diagnoses

While temple-to-temple headaches are commonly migraine or tension-type headaches, consider temporal arteritis in patients over age 50 with new-onset temple headaches, as the ESR can be normal in 10-36% of cases 5. Additionally, nerve entrapment of the zygomaticotemporal or auriculotemporal nerves can cause temple pain and is diagnosed by physical examination of the temporal fossa and injection of local anesthetic over the tender nerve 6.