What is the treatment for a severe, bilateral temporal headache with a pain intensity of maximum severity?

From the Guidelines

For a severe bilateral temple and lower head headache with a pain level of 10/10, I recommend starting with over-the-counter pain relievers such as ibuprofen (400-600mg) or acetaminophen (1000mg) every 6 hours as needed, as evidence suggests that non-steroidal anti-inflammatory drugs (NSAIDs) are first-line treatment for most patients with migraine 1.

Key Considerations

• Apply a cold compress to the temples for 15-20 minutes while resting in a dark, quiet room to help alleviate pain.
• Stay hydrated and consider caffeine intake (a cup of coffee or tea) which can enhance pain medication effectiveness.
• If this is a recurring pattern or doesn't respond within 24 hours, seek medical attention as it could indicate tension headache, migraine, or more serious conditions.

Treatment Approach

• For immediate relief of such severe pain, combination therapy may be most effective - taking both acetaminophen and an NSAID (like ibuprofen) together, as they work through different mechanisms 1.
• Avoid alcohol, maintain regular sleep patterns, and practice stress reduction techniques like deep breathing.
• These bilateral temple headaches often result from muscle tension, stress, dehydration, or eye strain, so addressing these underlying factors is crucial for long-term management.

Long-term Management

• Migraine sufferers should be evaluated for use of preventive therapy, with recommended first-line agents including propranolol, timolol, amitriptyline, divalproex sodium, and sodium valproate 1.
• Educate patients about the control of acute attacks and preventive therapy, and engage them in the formulation of a management plan, with regular reevaluation of therapy 1.

From the FDA Drug Label

The efficacy of sumatriptan tablets in the acute treatment of migraine headaches was demonstrated in 3, randomized, double-blind, placebo-controlled trials. In all 3 trials, the percentage of patients achieving headache response 2 and 4 hours after treatment was significantly greater among patients receiving sumatriptan tablets at all doses compared with those who received placebo

Treatment of Headache: Sumatriptan tablets are effective in the acute treatment of migraine headaches.

• The medication has been shown to significantly reduce headache severity from moderate or severe pain to mild or no pain within 2 to 4 hours after dosing.
• Doses of 25,50, and 100 mg were compared with placebo in the treatment of migraine attacks, with no statistically significant differences between the 50 mg and 100 mg dose groups in any trial.
• However, it is essential to note that sumatriptan is contraindicated in patients with certain conditions, such as CAD, Prinzmetal’s variant angina, Wolff-Parkinson-White syndrome, and a history of stroke or TIA 2.
• Before administering sumatriptan, it is crucial to evaluate the patient's cardiovascular risk factors and consider a cardiac evaluation if necessary 2.
• Additionally, sumatriptan should be used with caution in patients with a history of epilepsy or conditions associated with a lowered seizure threshold 2.

From the Research

Treatment Options for Headache

• The treatment of headaches involves a careful history and physical examination to determine the underlying cause of the headache 3.
• For acute treatment of headache, early initiation of therapy and adequate dosing at first dose are important, and careful attention should be paid to avoiding too frequent administration of acute therapy to prevent medication overuse headaches 3.
• Several medications are considered effective for the treatment of acute migraine attacks, including triptans, acetaminophen, and non-steroid anti-inflammation drugs (NSAIDs) such as aspirin, diclofenac, ibuprofen, and naproxen 4.
• For mild to moderate migraine attacks, oral NSAIDs are the first choice, while for moderate to severe attacks, oral or nasal spray triptans and ergotamine/caffeine compounds are recommended 4.
• Preventive treatment is indicated for frequent headaches, and successful treatment entails low-dose medication with careful titration and monitoring of headache frequency 3.
• Behavioral strategies are also important and should be part of any comprehensive headache management plan 3.

Medication Options

• Simple analgesics, such as acetaminophen, have evidence-based effectiveness and are widely regarded as first-line medications for the acute treatment of tension-type headache 5.
• Preventive treatments, such as amitriptyline, venlafaxine, and mirtazapine, may be considered in individuals with frequent episodic and chronic tension-type headache 5.
• Opioids should always be avoided in the treatment of acute migraine attacks due to the risk of serious adverse events 4.

Diagnostic Approach

• A detailed history and physical examination can distinguish between key features of a benign primary headache and concerning symptoms that warrant further evaluation for a secondary headache 6.
• The use of a systematic framework, such as the SNNOOP10 mnemonic, can help detect life-threatening secondary causes of headaches 6.
• Red flag signs or symptoms, such as acute thunderclap headache, fever, and meningeal irritation on physical examination, warrant immediate evaluation 6.