What are the potential causes and recommended treatments for a throbbing headache on the left front side of the head, including the neck, and causing nausea?

Throbbing Left-Sided Frontal Headache with Neck Pain and Nausea

This presentation is consistent with migraine, and you should start treatment immediately with combination therapy: an NSAID (ibuprofen 400-800 mg or naproxen 500-825 mg) plus an antiemetic (metoclopramide 10 mg), taken as early as possible during the attack. 1, 2

Immediate Assessment for Red Flags

Before treating as primary headache, rapidly screen for secondary causes that require urgent evaluation:

• Thunderclap onset (worst headache of life, reaching peak within seconds to minutes) suggests subarachnoid hemorrhage and requires immediate head CT 1, 3
• Fever with neck stiffness indicates possible meningitis 1, 3
• Focal neurological deficits (weakness, vision changes, speech problems) suggest stroke or space-occupying lesion 1, 4
• Recent head trauma raises concern for subdural hematoma 1, 4
• Age >50 years with new-onset headache warrants consideration of temporal arteritis 1
• Progressive worsening pattern or headache aggravated by Valsalva maneuver suggests intracranial hypertension 1, 4

If any red flags are present, obtain neuroimaging (MRI preferred, or CT if acute hemorrhage suspected) before treating as primary headache 4, 3

First-Line Treatment Algorithm

For Mild to Moderate Severity:

• Start with NSAIDs alone: Ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 1000 mg 1, 2
• Add antiemetic 20-30 minutes before NSAID if nausea is prominent: metoclopramide 10 mg provides both antiemetic effect and direct analgesic benefit through central dopamine receptor antagonism 1, 2
• Take medication early in the attack while pain is still mild for maximum effectiveness 1, 2

For Moderate to Severe Severity or NSAID Failure:

• Escalate to triptan + NSAID combination: Sumatriptan 50-100 mg PLUS naproxen sodium 500 mg provides superior efficacy compared to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 2
• Alternative oral triptans if sumatriptan fails after 2-3 attempts: rizatriptan 10 mg (fastest oral triptan, peak at 60-90 minutes), eletriptan 40 mg, or zolmitriptan 2.5-5 mg 2
• For severe nausea/vomiting: Consider subcutaneous sumatriptan 6 mg (59% complete pain relief by 2 hours, onset within 15 minutes) or intranasal formulations 1, 2

Critical Frequency Limitation

Restrict all acute medications to no more than 2 days per week (10 days per month) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches 1, 2

Addressing the Neck Component

The neck pain and occipital location suggest possible cervical strain as a concussion-associated condition, which involves somatosensory dysfunction from injury to cervical structures 1. This presentation is common when cervical and migraine mechanisms overlap:

• Palpate cervical spine, paraspinal muscles, and suboccipital region for tenderness 1
• Assess cervical range of motion and whether neck movement worsens headache 1
• If significant cervical component is present, consider physical therapy referral after acute phase 1

When to Initiate Preventive Therapy

If headaches occur more than 2 days per month with significant disability, or if you find yourself needing acute treatment more than twice weekly, preventive therapy is indicated 1, 2:

• First-line preventive options: Propranolol 80-240 mg/day, topiramate, or amitriptyline 30-150 mg/day 2
• Preventive therapy requires 2-3 months to assess efficacy for oral agents 1
• Goal is ≥50% reduction in attack frequency 2

Medications to Absolutely Avoid

• Never use opioids (hydromorphone, meperidine) or butalbital-containing compounds for migraine—they have questionable efficacy, cause dependency, trigger rebound headaches, and lose effectiveness over time 1, 2
• Avoid oral ergot alkaloids (ergotamine)—they are poorly effective and potentially toxic 1

Common Pitfall to Avoid

Do not allow yourself to increase frequency of acute medication use in response to persistent headaches—this creates a vicious cycle of medication-overuse headache 1, 2. Instead, transition to preventive therapy while optimizing your acute treatment strategy with the combination approach described above 2.