What is the best course of treatment for an adult patient with a history of migraines or tension headaches, presenting with a throbbing headache on the left front side of the head and neck, accompanied by nausea, which resolves with head movement and recurs at rest?

Positional Headache with Movement-Related Relief

This presentation is highly atypical for migraine and strongly suggests a cerebrospinal fluid (CSF) pressure disorder—most likely spontaneous intracranial hypotension (low CSF pressure headache)—which requires urgent neuroimaging and specialist evaluation rather than standard migraine treatment. 1

Critical Diagnostic Distinction

The key feature that distinguishes this from typical migraine is the orthostatic pattern: pain that stops with movement/lying down and worsens at rest/upright position. This is the opposite of typical migraine, which worsens with movement and improves with rest. 1

Red Flags Requiring Immediate Investigation

• New or recent onset headache with positional characteristics warrants urgent diagnostic testing, as this pattern suggests secondary headache disorder rather than primary migraine 1
• Headache brought on by postural changes is a specific red flag that increases likelihood of secondary causes requiring neuroimaging 1
• The combination of unilateral throbbing pain with nausea can occur in CSF leak headaches, mimicking migraine but with the critical orthostatic component 1

Recommended Diagnostic Approach

Obtain brain MRI with gadolinium contrast as the diagnostic test of choice to evaluate for:

• Pachymeningeal (dural) enhancement suggesting CSF leak 1
• Brain sagging or subdural fluid collections 1
• Venous sinus thrombosis (another cause of positional headache) 1

When to Use CT Instead

• CT brain is indicated only if acute trauma or abrupt thunderclap onset is present, but MRI remains superior for evaluating positional headaches 1

If This Were Typical Migraine (Pain Worsens with Movement)

Only if imaging rules out secondary causes and the positional pattern is mischaracterized should you proceed with migraine treatment:

Acute Treatment Algorithm

First-line for moderate-to-severe migraine with nausea: Combination therapy of sumatriptan 50-100 mg PLUS naproxen sodium 500 mg, taken together at headache onset. 2

• This combination provides 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to either agent alone 2
• Add metoclopramide 10 mg orally 20-30 minutes before the combination for synergistic analgesia and nausea control 2, 3

Alternative Routes for Severe Nausea

• Subcutaneous sumatriptan 6 mg provides highest efficacy with 59% complete pain relief by 2 hours and onset within 15 minutes 2
• Intranasal sumatriptan 5-20 mg when significant vomiting prevents oral medication 2

IV Treatment for Refractory Cases

Metoclopramide 10 mg IV plus ketorolac 30 mg IV represents first-line IV combination for severe attacks requiring emergency treatment 2, 3

• Metoclopramide provides direct analgesic effects through central dopamine receptor antagonism beyond antiemetic properties 2
• Ketorolac has rapid onset with 6-hour duration and minimal rebound headache risk 2, 3
• Prochlorperazine 10 mg IV is equally effective alternative to metoclopramide 4

Critical Medication Frequency Limitation

Limit ALL acute migraine medications to no more than 2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily chronic headaches 2, 3

• If headaches occur more than twice weekly, initiate preventive therapy immediately rather than increasing acute medication frequency 2
• Triptans trigger medication-overuse headache at ≥10 days/month; NSAIDs at ≥15 days/month 2

Common Pitfall to Avoid

Do not treat positional headaches empirically as migraine without neuroimaging. The orthostatic pattern (relief with lying down, worsening upright) is a red flag for secondary causes including CSF leak, venous sinus thrombosis, or intracranial mass lesions that require specific interventions beyond migraine treatment. 1 Missing these diagnoses can lead to serious complications including subdural hematomas in CSF leak cases.