What are the treatment options for a patient experiencing a headache with eyebrow pain and photophobia?

Headache with Eyebrow Pain and Photophobia: Treatment Approach

This presentation is most consistent with migraine, and treatment should begin with acute therapy using combination analgesics (aspirin + acetaminophen + caffeine OR naproxen sodium 500-825 mg) at headache onset, while simultaneously evaluating for preventive therapy if attacks occur ≥2 times per month. 1, 2

Diagnostic Confirmation

The combination of headache with eyebrow (supraorbital) pain and photophobia strongly suggests migraine rather than other primary headache disorders. 3

Key diagnostic features to document:

• Pain characteristics: Unilateral or bilateral location, throbbing quality, moderate-to-severe intensity, worsening with routine physical activity 1
• Associated symptoms: Presence of nausea/vomiting, phonophobia (sound sensitivity) in addition to photophobia 1
• Attack duration: Typically 4-72 hours when untreated 1
• Frequency: Number of headache days per month (critical for determining if chronic migraine is present) 1, 3

Photophobia is a cardinal migraine symptom occurring in the majority of migraine patients and is highly specific for this diagnosis. 3 Research confirms that migraineurs demonstrate the highest photophobia scores (6.63 out of 8) compared to other headache disorders. 4

Critical Red Flags Requiring Urgent Evaluation

Before initiating migraine treatment, exclude secondary causes if any of these features are present: 1, 2

• New onset after age 50 years 1, 2
• Rapidly increasing headache frequency or "worst headache of life" 1
• Focal neurologic signs or symptoms that persist 1, 3
• Headache awakening patient from sleep 1
• Fever, neck stiffness, or altered mental status 1
• Recent head trauma 3
• Headache worsening with Valsalva maneuver (suggests Chiari malformation or intracranial mass) 2

If red flags are present, obtain neuroimaging (MRI preferred over CT) before treating as primary headache. 1, 2

Acute Treatment Strategy

First-line acute therapy options (choose one): 2, 5

• Naproxen sodium 500-825 mg at headache onset, can repeat every 2-6 hours (maximum 1.5 g/day) 2
• Combination aspirin + acetaminophen + caffeine for moderate-to-severe attacks 2
• Sumatriptan/naproxen combination (TREXIMET) provides superior sustained pain-free rates (23-25% at 24 hours) compared to either agent alone or placebo 5

Critical medication overuse prevention: Limit acute treatment to maximum 2 days per week to prevent medication overuse headache (MOH), which creates a vicious cycle of increasing headache frequency leading to daily headaches. 1, 2, 6 This applies to all acute medications including triptans, NSAIDs, and combination analgesics. 1

When to Initiate Preventive Therapy

Start preventive therapy if: 2

• Headaches occur ≥2 times per month causing significant disability 2
• Acute medication required >2 days per week 6
• Continuous headache of prolonged duration is present 2

First-line preventive options: 2

• Propranolol 80-160 mg daily (long-acting formulation preferred) 2
• Topiramate (has dual benefit of appetite suppression/weight loss and carbonic anhydrase inhibition, but caution regarding depression, cognitive slowing, and reduced oral contraceptive efficacy) 1
• CGRP monoclonal antibodies 2
• OnabotulinumtoxinA for chronic migraine 2

Avoid preventive agents that cause weight gain (beta blockers, tricyclic antidepressants, sodium valproate) or worsen depression (beta blockers, topiramate) in appropriate patient populations. 1

Special Consideration: Cluster Headache Exclusion

While less likely given the presentation, cluster headache must be excluded if the patient describes: 1, 6

• Severe unilateral orbital/supraorbital pain lasting 15-180 minutes 1, 6
• Ipsilateral autonomic features: lacrimation, nasal congestion, rhinorrhea, forehead/facial sweating, ptosis, miosis, or eyelid edema 1, 6
• Attack frequency of 1-8 per day during cluster periods 1, 6

If cluster headache is diagnosed, high-flow oxygen therapy at 12-15 liters/minute via non-rebreather mask for 15-20 minutes is the gold-standard first-line treatment, providing rapid relief within 15 minutes in 70-80% of patients with no contraindications or medication overuse risk. 2, 6

Headache Diary Implementation

Implement a daily headache diary documenting: 3

• Headache frequency and duration 3
• Pain intensity (0-10 scale) 3
• Accompanying symptoms (photophobia, phonophobia, nausea) 3
• All acute medication use (to monitor for overuse) 3
• Potential triggers (foods, stress, sleep changes, hormonal factors) 1

This diary is essential for determining if chronic migraine criteria are met (≥15 headache days per month for >3 months, with migraine features on ≥8 days per month). 1, 3

Follow-Up and Referral Criteria

Re-evaluate within 2-3 months to assess: 2

• Attack frequency and severity reduction 2
• Disability improvement 2
• Medication adverse events 2
• Treatment adherence 2

Refer to neurology if: 2

• Diagnosis remains uncertain after thorough evaluation 2
• Poor response to preventive strategies after adequate trials 2
• Motor weakness or persistent aura develops 2
• Cluster headache is diagnosed (requires complex treatment management) 6

Common Pitfalls to Avoid

Do not dismiss daily or near-daily headaches as "not migraine" — chronic migraine by definition occurs ≥15 days per month and is a recognized diagnostic entity. 3

Do not order routine neuroimaging in the absence of red flags — imaging is only indicated when clinical features suggest secondary headache disorders, and unnecessary imaging can be harmful. 1, 3

Do not use acetaminophen alone for migraine treatment, as it is ineffective for moderate-to-severe migraine. 6

Do not prescribe opioids routinely due to risk of dependency, rebound headaches, and loss of efficacy. 6

Do not overlook medication overuse — actively quantify all acute medication use, as MOH frequently complicates chronic migraine and prevents treatment optimization. 1, 3