What could be causing my severe, strobing headache on the left side and how should I manage it?

Severe Unilateral Strobing Headache: Diagnosis and Management

Your severe, strobing (throbbing) headache on the left side is most consistent with an acute migraine attack, and you should treat it immediately with combination therapy of an NSAID plus a triptan if the pain is moderate to severe, or an NSAID alone if mild to moderate. 1

Immediate Assessment for Red Flags

Before treating as migraine, rule out dangerous secondary causes by checking for:

• Thunderclap onset (sudden, maximal intensity within seconds) - requires immediate emergency evaluation 2
• Fever, neck stiffness, or altered consciousness - suggests meningitis or encephalitis 2
• New neurologic deficits (weakness, vision loss, speech difficulty) - requires urgent imaging 3
• First severe headache after age 50 - higher risk of secondary causes 3
• Progressive worsening over days/weeks - concerning for mass lesion 3

If any red flags are present, seek emergency evaluation immediately with noncontrast head CT and possible lumbar puncture 2. If none are present, proceed with acute migraine treatment.

First-Line Acute Treatment Algorithm

For Mild to Moderate Pain (Can Function With Difficulty)

Start with NSAIDs as monotherapy: 1

• Naproxen sodium 500-825 mg at headache onset (preferred for longer duration of action) 1
• Ibuprofen 400-800 mg as alternative 1
• Aspirin 1000 mg as alternative 1

Add caffeine 100-200 mg for synergistic analgesic effect (equivalent to 1-2 cups of coffee) 1

For Moderate to Severe Pain (Disabling, Cannot Function)

Use combination therapy - this is superior to either agent alone: 1

• Sumatriptan 50-100 mg PLUS naproxen sodium 500 mg taken together at headache onset 1
• This combination provides 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to either medication alone 1

Alternative triptan options if sumatriptan unavailable: 1

• Rizatriptan, zolmitriptan, or naratriptan 1

If Significant Nausea/Vomiting Present

Add antiemetic 20-30 minutes before other medications: 1

• Metoclopramide 10 mg (provides direct analgesic benefit beyond treating nausea) 1
• Prochlorperazine 25 mg as alternative 1

Critical Frequency Limitation to Prevent Rebound Headaches

Limit ALL acute headache medications to no more than 2 days per week (10 days per month). 1, 4 Using acute treatments more frequently causes medication-overuse headache, creating a vicious cycle where headaches become daily and medications stop working 1, 4. This is one of the most common pitfalls in headache management.

When to Escalate Treatment

If NSAIDs Fail After 2-3 Migraine Episodes

Switch to triptan therapy for future attacks 1

If Oral Medications Fail Due to Rapid Progression or Vomiting

Subcutaneous sumatriptan 6 mg provides the fastest relief (within 15 minutes) with highest efficacy - 59% achieve complete pain relief by 2 hours 1

If You Need Acute Treatment More Than Twice Weekly

Initiate preventive therapy immediately rather than increasing frequency of acute medications 1. First-line preventive options include:

• Propranolol 80-240 mg/day 1
• Topiramate (dose titrated based on response) 1
• Amitriptyline 30-150 mg/day (especially if you also have tension-type headaches) 1

Preventive therapy requires 2-3 months to assess efficacy 1

Medications to Absolutely Avoid

Never use opioids (hydrocodone, oxycodone, morphine) or butalbital-containing compounds for migraine treatment 1. These medications:

• Have questionable efficacy for migraine 1
• Lead to dependency and medication-overuse headache 3, 1
• Cause progressive loss of effectiveness over time 3
• Should only be considered as absolute last resort when all other options have failed or are contraindicated 1

Contraindications Requiring Alternative Approach

Do not use triptans if you have: 1

• Ischemic heart disease or previous heart attack 1
• Uncontrolled hypertension 1
• Cerebrovascular disease or previous stroke 1
• Peripheral vascular disease 1

In these cases, use gepants instead: 1

• Ubrogepant 50-100 mg or rimegepant - these have no vasoconstriction and are safe with cardiovascular disease 1

When to Seek Further Evaluation

See a physician if: 3

• Headaches occur more than 2 days per week (need preventive therapy) 3, 1
• Pattern changes or headaches worsen progressively 3
• Neurologic symptoms develop (weakness, vision changes, confusion) 3
• Current medications stop working after previously being effective 1
• You're using acute medications more than twice weekly (risk of medication-overuse headache) 1, 4

Neuroimaging is NOT routinely needed if you have typical migraine features, normal neurologic examination, and no red flag symptoms 3. However, imaging should be considered if headaches have atypical features or don't meet strict migraine criteria 3.