What could be causing my recurring afternoon headaches and head pressure, and how can I manage these symptoms?

Afternoon Headaches with Head Pressure: Evaluation and Management

Your recurring afternoon headaches with head pressure most likely represent tension-type headache or migraine, but you need to track the frequency and characteristics with a headache diary to guide appropriate treatment, starting with NSAIDs for mild-moderate symptoms and escalating to triptans if inadequate response.

Initial Diagnostic Approach

Keep a headache diary immediately to document the number of headache days per month, as patients cannot accurately report frequency without a written record 1. Specifically track:

• Frequency: Ask yourself "Do I have a headache of some type on 15 or more days per month?" 1
• Timing pattern: Note that afternoon onset may suggest tension-type features or external compression triggers 2
• Pain characteristics: Bilateral pressing/tightening quality suggests tension-type headache, while unilateral throbbing with nausea/photophobia indicates migraine 3
• Severity: Document both severe headache days AND milder headaches, as patients often underreport the latter 1

Red Flags Requiring Urgent Evaluation

Seek immediate medical attention if you develop any of these warning signs:

• Thunderclap onset (sudden, severe headache reaching maximum intensity within seconds) 3
• Headache awakening you from sleep 3
• Rapidly increasing frequency of headaches 3
• Focal neurologic symptoms (weakness, numbness, vision changes) 3, 4
• Persistent headache following head trauma 3

Acute Treatment Strategy

For Mild to Moderate Headaches

Start with NSAIDs as first-line therapy: ibuprofen, naproxen sodium, or aspirin 3. Take medication early in the attack with adequate dosing at the first dose 5.

For Moderate to Severe Headaches or NSAID Failure

Add a triptan (sumatriptan, rizatriptan, or naratriptan) if NSAIDs alone fail to provide adequate relief 3. The American College of Physicians provides strong recommendation with moderate-certainty evidence for this approach 3.

Critical Medication Overuse Warning

Never use acute medications more than 10-15 days per month, as this causes medication overuse headache (MOH) and worsens your chronic headache pattern 1, 6, 4. Specifically:

• Simple analgesics: Maximum 15 days per month 6
• Triptans/combination medications: Maximum 10 days per month 6
• Opioids: Should NEVER be prescribed for headaches due to dependency risk, rebound headaches, and eventual loss of efficacy 6, 5

When to Consider Preventive Therapy

Preventive medication is indicated if you have:

• More than 2 headaches per week 3
• Frequent use of acute medications (approaching the 10-15 day threshold) 3
• Significant disability despite acute treatment 3
• 15 or more headache days per month (chronic migraine) 1

Evidence-Based Preventive Options

If you meet criteria for chronic migraine (≥15 headache days/month), topiramate is the first-line preventive medication due to lower cost and proven efficacy in randomized controlled trials 1. Alternative evidence-based options include:

• OnabotulinumtoxinA (Botox): FDA-approved for chronic migraine prophylaxis, typically reserved for patients who fail 2-3 other preventives 1
• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab): Proven beneficial after failure of at least two other preventives 1

Important caveat: Beta blockers, candesartan, and amitriptyline lack robust randomized controlled trial data for chronic migraine, though commonly used in clinical practice 1.

Lifestyle Modifications (Essential for All Patients)

Implement these changes immediately, as they have considerable impact on headache disorders 6:

• Regular meals and adequate hydration 6
• Consistent sleep schedule with good sleep hygiene 6
• Regular exercise program 6
• Stress management techniques 6
• Limit caffeine intake 6

Identify and Modify Risk Factors

Address modifiable triggers that may be causing afternoon headaches:

• External compression: Remove tight hats, headbands, or goggles that press on the scalp, as prolonged compression of trigeminal or occipital nerve branches causes constant pain at pressure points 2
• Obesity: Recognized risk factor for transformation to chronic migraine 1
• Caffeine overuse: Can trigger and perpetuate headaches 1
• Obstructive sleep apnea: Should be evaluated if present 1
• Psychiatric comorbidities: Depression and anxiety increase headache frequency 1
• Stress: Behavioral interventions help modify responses to stressful life events 1

When to Seek Specialist Care

Referral to neurology or headache specialist is indicated for:

• Chronic migraine (≥15 headache days/month) 1
• Medication overuse headache requiring withdrawal management 1
• Failure of multiple preventive medications 1
• Diagnostic uncertainty or atypical features 1

Your primary care physician should continue managing you even after specialist referral, monitoring treatment response and maintaining the headache diary 1.

Common Pitfalls to Avoid

• Do not assume chronic daily headache is benign without proper evaluation 4
• Never attribute symptoms to migraine without tracking frequency and characteristics 1
• Avoid too frequent administration of acute therapy, which creates medication overuse headache 5
• Do not delay preventive therapy if you meet frequency criteria 3