What is the cause of and recommended treatment for a patient experiencing neck and shoulder stiffness with throbbing headaches lasting several days, minimally relieved by Panadol (acetaminophen), and affecting daily activities?

Assessment and Management of Neck Stiffness with Throbbing Headaches

Most Likely Diagnosis

This presentation is most consistent with cervicogenic headache or migraine with associated neck pain, both of which commonly present together and require similar initial management approaches. 1 The combination of neck/shoulder stiffness with throbbing headaches lasting several days that minimally respond to acetaminophen alone suggests either migraine (which frequently presents with neck pain) or tension-type headache with cervical muscle involvement. 2

Immediate Treatment Recommendations

Start with combination therapy of an NSAID plus acetaminophen, as this provides superior efficacy compared to acetaminophen alone for moderate headache. 3

First-Line Acute Treatment

• Naproxen 500-825 mg at headache onset, combined with acetaminophen 1000 mg 4, 3
• This combination addresses both the inflammatory component and provides synergistic analgesia 3
• Can be repeated every 2-6 hours as needed, maximum 1.5 g naproxen per day 4
• Critical limitation: Restrict use to no more than 2 days per week to prevent medication-overuse headache 4, 3

Add Antiemetic for Enhanced Efficacy

• Metoclopramide 10 mg taken 20-30 minutes before the NSAID provides direct analgesic effects beyond just treating nausea 4
• This combination (acetaminophen 1000 mg + metoclopramide 10 mg) has been shown equivalent to sumatriptan 100 mg for headache relief 5
• Metoclopramide works through central dopamine receptor antagonism, providing independent pain relief 4

When to Escalate Treatment

If the above regimen fails after 2-3 headache episodes, escalate to triptan therapy for moderate-to-severe attacks. 4

Second-Line Options

• Sumatriptan 50-100 mg plus naproxen 500 mg provides superior efficacy to either agent alone 4
• Alternative triptans include rizatriptan 10 mg (fastest oral triptan, reaching peak in 60-90 minutes) 4
• For severe nausea/vomiting, consider intranasal or subcutaneous sumatriptan 4

Red Flags Requiring Urgent Evaluation

Before proceeding with treatment, rule out secondary causes of headache, particularly given the neck involvement following symptom onset. 1

Warning Signs to Assess

• Abrupt onset or "thunderclap" pattern 2
• Neurologic deficits on examination 2
• Fever with neck stiffness (meningeal signs) 4
• Progressive worsening despite treatment 4
• Age >50 years with new-onset headache 2
• History of trauma (even if remote) 6

Preventive Therapy Indications

If this patient requires acute treatment more than twice weekly, initiate preventive therapy immediately to break the cycle of frequent headaches. 1

When to Start Prevention

• Two or more attacks per month producing disability lasting 3+ days 1
• Use of acute medications more than twice weekly 1
• Failure of or contraindication to acute treatments 1
• Risk of developing medication-overuse headache 1, 3

First-Line Preventive Options

• Topiramate is the only agent with proven efficacy in randomized controlled trials for chronic migraine 1
• Amitriptyline 30-150 mg/day is particularly useful for mixed migraine and tension-type headache with neck involvement 1
• Propranolol 80-240 mg/day or other beta-blockers without intrinsic sympathomimetic activity 4

Critical Pitfall to Avoid

Do not allow the patient to increase frequency of acute medication use in response to treatment failure, as this creates medication-overuse headache with daily headaches. 1, 4, 3 Instead, transition to preventive therapy while optimizing the acute treatment strategy. 4

Medication-Overuse Headache Thresholds

• NSAIDs/acetaminophen: ≥15 days per month 3
• Triptans: ≥10 days per month 3
• This pattern leads to increasing headache frequency and potentially daily headaches 1

Non-Pharmacological Adjuncts

Identify and address modifiable triggers including sleep patterns, stress, caffeine intake, and hydration status. 1, 3

• Maintain regular sleep schedule and meal timing 3
• Stay well hydrated 3
• Regular physical activity 3
• Consider headache diary to track patterns and triggers 1

Contraindications to Consider

• NSAIDs should be avoided in patients with renal impairment (CrCl <30 mL/min), active GI bleeding, or aspirin-induced asthma 4
• Triptans are contraindicated in cardiovascular disease, uncontrolled hypertension, or cerebrovascular disease 4, 2
• Metoclopramide is contraindicated in seizure disorder, GI obstruction, or pheochromocytoma 4