What are the potential causes and treatment options for a middle-aged adult with a history of migraines, presenting with a right-sided headache and ear tearing?

Right-Sided Headache with Ear Tearing

This presentation is highly suggestive of cluster headache or migraine with autonomic features, and you should initiate treatment with a triptan plus NSAID combination immediately while ruling out secondary causes. 1

Differential Diagnosis and Red Flags

The combination of unilateral headache with ipsilateral tearing (lacrimation) points toward two primary possibilities:

• Cluster headache - characterized by severe unilateral pain with ipsilateral autonomic features including tearing, nasal congestion, and restlessness 2
• Migraine with autonomic features - can present with unilateral pain and tearing, though typically less severe autonomic symptoms than cluster headache 3

Critical red flags requiring urgent neuroimaging include: 1

• Headache worsened by Valsalva maneuver
• Awakening from sleep with headache
• New onset in older person (>50 years)
• Progressive worsening pattern
• Abnormal neurologic examination findings

Immediate Treatment Algorithm

For Moderate to Severe Attacks (Most Likely Scenario)

First-line combination therapy: 1

• Sumatriptan 50-100 mg PLUS naproxen sodium 500 mg - this combination provides superior efficacy compared to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 4
• Take medication as early as possible during the attack for maximum effectiveness 1, 5

If severe with rapid onset or significant nausea: 4

• Subcutaneous sumatriptan 6 mg - provides pain relief in 70-82% of patients within 15 minutes, the fastest and most effective route 4
• Add antiemetic (metoclopramide 10 mg or prochlorperazine 25 mg) if nausea present 1

For Mild to Moderate Attacks

Start with NSAID monotherapy: 1

• Naproxen sodium 500-825 mg at onset 4
• Ibuprofen 400-800 mg 1
• If inadequate response after 2-3 attacks, escalate to triptan combination 4

Critical Medication Frequency Limitation

Strictly limit all acute medications to no more than 2 days per week (10 days per month) to prevent medication-overuse headache. 1, 4 This threshold is:

• ≥10 days/month for triptans 5
• ≥15 days/month for NSAIDs 5

If requiring acute treatment more frequently, initiate preventive therapy immediately rather than increasing acute medication frequency. 6

Contraindications and Safety Considerations

Triptans are absolutely contraindicated in: 7

• Ischemic heart disease or previous myocardial infarction
• Uncontrolled hypertension
• Cerebrovascular disease (stroke, TIA)
• Peripheral vascular disease
• Hemiplegic or basilar migraine

For patients with cardiovascular contraindications, use: 1

• CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant 1
• Lasmiditan (5-HT1F agonist without vasoconstriction) - note 8-hour driving restriction 4

When to Consider Preventive Therapy

Preventive therapy is indicated if: 6

• Two or more attacks per month producing disability for 3+ days
• Using acute medications more than 2 days per week
• Contraindication to or failure of acute treatments
• Patient preference to reduce attack frequency

First-line preventive options include: 6

• Propranolol 80-240 mg/day (avoid in asthma, diabetes, depression) 6
• Topiramate 25-100 mg/day (start low, titrate slowly) 6
• Amitriptyline 30-150 mg/day (especially if mixed migraine/tension-type) 6

Medications to Absolutely Avoid

Never prescribe opioids or butalbital-containing compounds - they have questionable efficacy, lead to dependency, cause rebound headaches, and result in loss of efficacy over time. 1, 4

Common Pitfalls to Avoid

• Taking medication too late in the attack - triptans work best when taken early while pain is still mild 4
• Allowing escalation of acute medication frequency - this creates a vicious cycle of medication-overuse headache 6
• Declaring treatment failure too early - try different triptans if one fails, as failure of one does not predict failure of others 6
• Ignoring lifestyle modifications - counsel on hydration, regular meals, consistent sleep, regular aerobic exercise, and stress management 1