What is the differential diagnosis and initial management for a patient presenting with a frontal headache?

Differential Diagnosis for Frontal Headache

Primary Headache Disorders

The most common cause of frontal headache is migraine, not sinusitis, despite widespread misconception among patients and clinicians. 1, 2

Migraine Without Aura

• Suspect migraine when frontal headache is unilateral, pulsating, moderate-to-severe intensity, and worsened by routine physical activity 3
• Accompanying symptoms include photophobia, phonophobia, nausea, and/or vomiting 3
• Attacks last 4-72 hours when untreated 3
• Requires at least five attacks meeting these criteria for diagnosis 3
• Family history of migraine strengthens the diagnosis, particularly with onset around puberty 3

Tension-Type Headache

• The vast majority of patients with symmetrical frontal or temporal headache have tension-type headache, affecting 38% of the population 1, 2
• Characterized by pressing, tightening, or nonpulsatile pain of mild-to-moderate intensity 3
• Bilateral location without aggravation by routine activity 3
• Less disabling than migraine 2

Trigeminal Autonomic Cephalalgias

• Front-orbital headache with autonomic symptoms (lacrimation, rhinorrhea, nasal congestion) suggests cluster headache or other trigeminal autonomic cephalalgias 4
• Severe unilateral pain lasting 15-180 minutes 3
• Requires precise history-taking as no single drug is universally effective 4

Secondary Headache Disorders

Acute Bacterial Sinusitis

• Genuine sinus headache is uncommon and confined to acute frontal sinusitis or sphenoiditis with blocked drainage 1, 3
• Unilateral infraorbital or supraorbital pain that increases when bending forward 3
• Pulsatile pain peaking in early evening and at night 3
• Associated with fever, unilateral nasal obstruction, and purulent discharge following viral upper respiratory infection 1
• Chronic sinusitis is NOT validated as a cause of headache unless relapsing into acute stage 1

Pott's Puffy Tumor

• Rare but serious complication of frontal sinusitis presenting with frontal headache, tenderness, and swelling 5
• Tense, erythematous swelling over frontal region with elevated inflammatory markers 5
• Can progress to epidural abscess requiring emergent neurosurgical intervention 5

Cardiac Ischemia

• Exertional frontal headache relieved by rest may indicate cardiac ischemia, particularly in older patients with cardiovascular risk factors 6
• Requires stress testing if suspected 6

Epileptic Headache

• Pressing-type frontal pain lasting several minutes to hours 4
• May be followed by tremor or convulsion 4
• EEG shows spike and wave activities 4

Red Flags Requiring Urgent Evaluation

Immediate neuroimaging with brain MRI is indicated when any of the following are present: 7, 2

• New-onset headache in patient over 50 years of age 7
• Progressively worsening headache pattern 7
• Headaches that wake patient from sleep 7
• Headaches worsened by Valsalva maneuver 7
• Abnormal neurological examination findings 7
• Thunderclap onset (subarachnoid hemorrhage) 3
• Meningeal signs, fever, neck stiffness (meningitis) 3
• Focal neurological symptoms 3
• Recent head trauma 3

Initial Management Approach

For Suspected Migraine

• First-line acute treatment: NSAIDs (aspirin, ibuprofen, or diclofenac potassium) plus antiemetic if necessary 3
• Second-line: Triptans if NSAIDs fail after three consecutive attacks 3
• Triptans most effective when taken early during mild headache phase 3
• Avoid triptans in patients with cardiovascular disease 3
• Third-line: Gepants (ubrogepant, rimegepant) or ditans (lasmiditan) if all triptans fail 3, 2

For Suspected Acute Bacterial Sinusitis

• First-line antibiotics: amoxicillin-clavulanate, cefuroxime-axetil, cefpodoxime-proxetil, or pristinamycin 3
• Duration: 7-10 days (cefuroxime-axetil and cefpodoxime-proxetil effective in 5 days) 3
• Fluoroquinolones (levofloxacin, moxifloxacin) reserved for frontal, fronto-ethmoidal, or sphenoidal sinusitis due to high complication risk 3

Diagnostic Workup

• Thyroid function tests (TSH, free T4) to rule out thyroid dysfunction causing both headache and other symptoms 7
• Complete blood count, basic metabolic panel, liver function tests 7
• Brain MRI with and without contrast is preferred neuroimaging when red flags present 7
• Headache diary documenting frequency, duration, intensity, and triggers 7

Common Pitfalls to Avoid

• Do not attribute chronic or recurrent frontal headaches to sinusitis without clear evidence of acute bacterial infection 1
• Nasal congestion during migraine is due to vasodilation of nasal mucosa, not sinusitis 1
• Avoid opioids and barbiturates for migraine treatment due to questionable efficacy and dependency risk 3
• Do not use triptans during aura phase—wait until headache begins 3
• Recurrent bacterial sinusitis (>2 episodes/year) warrants immunodeficiency workup 1