What is the management of a left temporal headache with pain around the eyes?

Management of Left Temporal Headache with Periorbital Pain

First, rule out cluster headache and secondary causes before treating as migraine, as the unilateral temporal location with periorbital pain fits the classic presentation of cluster headache, which requires different management than migraine. 1, 2, 3

Immediate Assessment for Red Flags

Before initiating any treatment, assess for the following urgent conditions that require immediate imaging and specialist evaluation:

• New onset after age 50 suggests temporal arteritis, mass lesions, or other serious pathology requiring urgent evaluation 4, 5
• Thunderclap onset (peaking within 1 second to 1 minute) indicates possible subarachnoid hemorrhage 4
• Focal neurological deficits or abnormal neurological examination mandate immediate MRI brain without contrast 4, 2
• Headache worsened by Valsalva maneuver (coughing, straining, bending) suggests increased intracranial pressure or Chiari malformation 4, 2
• Progressive worsening over days to weeks indicates evolving pathology 4
• Fever or signs of infection require urgent evaluation for meningitis or encephalitis 4

Distinguish Between Cluster Headache and Migraine

Cluster Headache Features (requires neurology referral):

• Severe unilateral orbital, supraorbital, or temporal pain lasting 15-180 minutes with attack frequency of 1-8 times per day 2, 3
• Ipsilateral autonomic symptoms: lacrimation, nasal congestion, rhinorrhea, forehead/facial sweating, ptosis, miosis, or eyelid edema 1, 3
• Patients typically pace or rock during attacks rather than lying still 3
• All cluster headache patients require referral to neurology due to complex treatment requirements 4, 2

Migraine Features:

• Duration of 4-72 hours (much longer than cluster headache) 3
• Unilateral location, throbbing character, moderate to severe intensity 1
• Associated symptoms: photophobia, phonophobia, nausea/vomiting 1, 3
• Patients prefer to lie still in a dark, quiet room 3

Acute Treatment Based on Diagnosis

If Cluster Headache:

• High-flow oxygen therapy at 12-15 liters per 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 2
• Subcutaneous sumatriptan 6 mg provides relief within 10 minutes in 70% of patients 3
• Intranasal zolmitriptan 10 mg as an alternative acute therapy 3
• Screen for cardiovascular risk factors (hypertension, hypercholesterolemia, smoking, obesity, diabetes, family history) before prescribing sumatriptan 3

If Migraine (Mild to Moderate):

• Naproxen sodium 500-825 mg at onset, which can be repeated every 2-6 hours (maximum 1.5 g/day) 1, 2
• Ibuprofen 400-800 mg every six hours (maximum 2.4 g/day) 1
• Combination aspirin + acetaminophen + caffeine for moderate-to-severe attacks 1, 2

If Migraine (Moderate to Severe or Poor Response to NSAIDs):

• Triptans (sumatriptan, rizatriptan, zolmitriptan, naratriptan) are migraine-specific drugs 1
• Combination therapy (aspirin 650-1000 mg + acetaminophen + caffeine) provides synergistic benefit 1, 6
• For nausea or vomiting, use non-oral routes of administration 1

Adjunctive Therapy:

• Metoclopramide 10 mg IV or orally 20-30 minutes before or with analgesics for nausea and improved gastric motility 1
• Prochlorperazine 25 mg orally or suppository can effectively relieve headache pain (maximum three doses per 24 hours) 1

Critical Medication Overuse Prevention

Limit acute treatment to no more than 2 days per week to prevent medication overuse headache, which creates a vicious cycle of increasing headache frequency leading to chronic daily headaches 2. This is a common pitfall that transforms episodic headaches into chronic daily headaches requiring withdrawal therapy 1.

When to Initiate Preventive Therapy

Consider preventive therapy if:

• Headaches occur two or more times per month causing significant disability 2
• Continuous headache of prolonged duration is present 2

Preventive Options for Migraine:

• Propranolol 80-160 mg daily (long-acting formulation) is first-line preventive therapy 2
• Topiramate is the only agent with proven efficacy in randomized controlled trials for chronic migraine 4
• OnabotulinumtoxinA is the only FDA-approved therapy for chronic migraine prophylaxis 4
• CGRP monoclonal antibodies for patients who have failed other preventive medications 1, 2

Preventive Options for Cluster Headache:

• Verapamil 360 mg/day is the prophylactic drug of choice, with ECG monitoring for PR interval prolongation at higher doses 3
• Oral corticosteroids or greater occipital nerve blockade as bridging therapy while verapamil takes effect 3
• Galcanezumab for episodic cluster headache (not chronic) 3

Neuroimaging Indications

MRI brain without contrast is the preferred imaging modality when indicated 4, 2. Obtain imaging if:

• Any red flags are present 4
• Unexplained abnormal findings on neurologic examination 4
• Atypical features that don't fit established primary headache patterns 4
• Occipital headache worsened by Valsalva (include sagittal T2-weighted sequence of craniocervical junction to evaluate for Chiari malformation) 2

Specialist Referral Criteria

Refer to neurology for:

• All cluster headaches (mandatory due to complex treatment requirements) 4, 2
• Chronic migraine (15 or more headache days per month) 4
• Headache with motor weakness 4
• Diagnosis remains uncertain after thorough evaluation 2
• Poor response to preventive strategies after adequate trials 2
• Persistent aura develops 2

Follow-Up Strategy

Re-evaluate within 2-3 months to assess attack frequency, severity, disability, adverse medication events, and adherence 2. This allows for timely adjustment of therapy and prevents progression to chronic patterns.