Headache with Ear Pain for One Week: Diagnostic and Management Approach
Immediate Diagnostic Priority: Rule Out Acute Otitis Media and Secondary Causes
Your first step is to perform otoscopy to visualize the tympanic membrane and assess for acute otitis media (AOM), which commonly presents with headache and ear pain. 1 Look specifically for tympanic membrane abnormalities including erythema, bulging, perforation, or middle ear effusion using pneumatic otoscopy if available. 1, 2
Critical Red Flags Requiring Urgent Evaluation
Examine for features that mandate immediate imaging or specialist referral:
- Fever with neck stiffness (suggests meningitis or intracranial complication) 1, 3
- Altered mental status or somnolence (may indicate sigmoid sinus thrombosis from chronic otitis media) 4
- Focal neurological deficits (suggests intracranial pathology) 1, 3
- Thunderclap onset or worst headache of life (excludes primary headache) 1, 5, 3
- Progressive worsening over one week (atypical for primary headache) 1, 3
- Cholesteatoma findings on otoscopy (granulation tissue, retraction pockets, perforation with debris) 1, 4
If any red flags are present, obtain urgent brain MRI and refer to neurology or otolaryngology immediately. 3, 4
Most Likely Diagnosis: Migraine Misattributed to "Sinus Headache"
Between 50-80% of patients diagnosed with "sinus headache" actually have migraine or other primary headaches. 6, 7 The combination of headache with perceived ear/sinus involvement is a classic migraine presentation that is frequently misdiagnosed. 8, 6
Diagnostic Criteria for Migraine Without Aura
Your patient likely has migraine if the headache includes:
- Unilateral or bilateral frontal/temporal location with photophobia or phonophobia 1, 5
- Moderate to severe intensity lasting 4-72 hours untreated 1, 5
- Nausea or vomiting (not required but supportive) 1, 5
- Worsening with routine physical activity 1, 5
The perceived "ear pain" in migraine results from trigeminal nerve activation and referred pain, not true otologic pathology. 8, 6
Acute Treatment Algorithm
First-Line: NSAIDs Plus Antiemetic
Start with naproxen 500-825 mg PLUS metoclopramide 10 mg orally at headache onset. 1, 5 Metoclopramide provides direct analgesic effects through central dopamine receptor antagonism beyond its antiemetic properties, creating synergistic pain relief. 5 Alternative NSAIDs include ibuprofen 400-800 mg or aspirin 1000 mg. 1, 5
Second-Line: Add Triptan if NSAIDs Fail After 2-3 Episodes
If NSAIDs provide inadequate relief after trying 2-3 headache episodes, escalate to sumatriptan 50-100 mg PLUS naproxen 500 mg at headache onset. 1, 5 This combination is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours. 5
Alternative triptans if sumatriptan fails:
- Rizatriptan 10 mg (fastest oral triptan, peak concentration 60-90 minutes) 5
- Eletriptan 40 mg or zolmitriptan 2.5-5 mg (reportedly more effective with fewer adverse effects than sumatriptan) 5
Third-Line: CGRP Antagonists (Gepants)
If all triptans fail after adequate trials, escalate to ubrogepant 50-100 mg or rimegepant at headache onset. 1, 5 These agents have no vasoconstriction and are safe for patients with cardiovascular contraindications to triptans. 5
Critical Medication Frequency Limit
Restrict ALL acute headache medications to no more than 2 days per week (≤10 days per month) to prevent medication-overuse headache. 1, 5 Using acute medications more frequently paradoxically increases headache frequency and can lead to daily headaches. 1, 5
When to Initiate Preventive Therapy
Start preventive therapy immediately if your patient requires acute treatment more than twice weekly or experiences ≥2 migraine attacks per month with disability lasting ≥3 days. 1
First-Line Preventive Options
- Propranolol 80-240 mg/day (strongest evidence among beta-blockers) 1, 5
- Topiramate 50-100 mg/day (FDA-approved for migraine prevention) 1, 3
- Candesartan (angiotensin-receptor blocker with good evidence) 1
Second-Line Preventive Options
- Amitriptyline 30-150 mg/day (preferred when comorbid depression, anxiety, or sleep disturbances exist) 1, 5
- Valproate 800-1500 mg/day (strictly contraindicated in women of childbearing potential due to teratogenic risk) 1, 5, 3
Preventive efficacy requires 2-3 months for oral agents to assess response. 5
Otologic Causes to Exclude
Acute Otitis Externa (AOE)
If otoscopy reveals ear canal swelling, erythema, or debris with tenderness on tragal palpation, diagnose AOE and treat with topical antibiotic eardrops (fluoroquinolone preferred). 1 AOE typically presents with severe otalgia worsened by manipulation of the auricle. 1
Referred Otalgia from Non-Otologic Sources
If otoscopy is normal, consider:
- Temporomandibular joint (TMJ) dysfunction (most common cause of referred otalgia): tenderness over TMJ, crepitus, history of bruxism or gum chewing 1, 6
- Dental pathology (caries, impacted molars): requires dental examination 1
- Upper aerodigestive tract malignancy (especially in patients >50 years with tobacco/alcohol use): requires complete head and neck examination 1
Medications to Absolutely Avoid
Never prescribe opioids (hydrocodone, oxycodone, codeine) or butalbital-containing compounds for headache. 1, 5 These agents have questionable efficacy, create two-fold higher risk of medication-overuse headache compared to NSAIDs/triptans, lead to dependency, and result in worse long-term outcomes. 5
Follow-Up and Safety-Net Instructions
Schedule follow-up within 48-72 hours if symptoms persist despite treatment. 5 Instruct the patient to return immediately for:
- Worsening to "worst headache of life" 5, 3
- New focal neurological deficits, seizure, or loss of consciousness 5, 3
- Fever with neck stiffness 1, 3
- Progressive worsening despite treatment 1, 3
Advise keeping a headache diary (paper or smartphone app) to track attack frequency, triggers, and medication use, which improves diagnostic accuracy and identifies modifiable triggers such as sleep deprivation, stress, and caffeine overuse. 5