What is the likely diagnosis and recommended management for a 43-year-old man with a three‑week history of mild right‑temporal headache that transiently worsens with coughing and has no red‑flag symptoms?

Likely Diagnosis: Primary Headache (Tension-Type or Mild Migraine) with Reassuring Clinical Course

This 43-year-old man most likely experienced a benign primary headache disorder that has already resolved, and no further acute intervention or imaging is indicated given the absence of red flags and spontaneous improvement. 1

Clinical Assessment and Red Flag Exclusion

Your patient's presentation lacks concerning features that would mandate urgent evaluation:

• Mild intensity (2/10) and insidious onset over 3 weeks argue strongly against dangerous secondary causes like subarachnoid hemorrhage, which typically presents as thunderclap headache reaching maximum intensity within seconds to minutes. 1
• Absence of focal neurological deficits (no weakness, sensory loss, coordination problems) markedly reduces the likelihood of serious intracranial pathology; focal deficits carry a likelihood ratio of approximately 5.3 for significant abnormality. 1, 2
• No neck stiffness, fever, altered consciousness, or papilledema effectively rules out meningitis, subarachnoid hemorrhage, and raised intracranial pressure from mass lesions. 1
• Age 43 years falls below the threshold of 50 years that triggers concern for temporal arteritis or other age-related secondary headaches. 1
• Spontaneous resolution after 3 weeks further supports a benign, self-limited process rather than progressive intracranial pathology. 1, 3

Interpretation of the Cough-Exacerbation Feature

• Headache transiently worsened by coughing is listed as a red flag for secondary headache in guidelines, but this feature has a modest likelihood ratio of only 2.3 for intracranial abnormality when considered in isolation. 1, 2
• In the absence of other red flags—particularly with mild severity, no neurological deficits, and spontaneous improvement—cough exacerbation alone does not mandate neuroimaging. 1, 2
• The guideline context for cough-related red flags primarily addresses patients with severe, progressive, or new-onset headaches; your patient's mild, resolving headache does not fit this high-risk profile. 1

Recommended Management

No Imaging Required

• Neuroimaging (CT or MRI) is indicated only when red-flag criteria are met, such as thunderclap onset, progressive worsening, focal neurological deficits, fever with neck stiffness, or new-onset headache after age 50. 1
• Routine imaging for typical headache without red flags exposes patients to unnecessary radiation (for CT), added cost, and the risk of incidental findings that may trigger further unwarranted testing. 1
• When a patient with typical headache characteristics has a fully normal physical examination, the probability of uncovering serious intracranial pathology is extremely low (≈ 0.2%), comparable to asymptomatic volunteers (≈ 0.4%). 1

Symptomatic Treatment (If Headache Recurs)

• NSAIDs (ibuprofen 400–800 mg or naproxen 500–825 mg) or acetaminophen 1000 mg are first-line therapy for mild-to-moderate headache. 4, 5
• Limit acute medication use to ≤ 2 days per week to prevent medication-overuse headache, which can paradoxically increase headache frequency and lead to daily headaches. 4

Follow-Up and Safety-Net Instructions

• Reassure the patient that the spontaneous resolution and absence of red flags indicate a benign process. 1, 3
• Provide return precautions: Instruct the patient to seek immediate evaluation if he develops thunderclap headache, focal neurological symptoms, fever with neck stiffness, altered consciousness, or progressive worsening. 1
• Consider a headache diary if episodes recur, to identify triggers and assess frequency for potential preventive therapy. 4

Common Pitfalls to Avoid

• Do not order neuroimaging solely because of patient anxiety or the presence of a single isolated red-flag feature (cough exacerbation) when all other clinical parameters are reassuring. Imaging should be reserved for cases with documented red-flag signs in the appropriate clinical context. 1
• Relying solely on neuroimaging without considering the complete clinical picture is a common pitfall; the history and physical examination remain the cornerstone of headache diagnosis. 1, 6
• Avoid prescribing opioids or butalbital-containing compounds for headache, as they have limited efficacy, high risk of medication-overuse headache, and potential for dependence. 4