In a 27‑year‑old male with a 1‑day history of left‑temporal continuous sharp headache (5/10) worsened by computer use, sleep deprivation, and mornings, partially relieved by paracetamol, now throbbing with dizziness and brief tremor‑like sensation, normal vital signs and physical examination, and recent change in astigmatic eyeglass prescription, what is the most likely diagnosis and appropriate management, including fit‑to‑work clearance?

Probable Migraine with Atypical Features – Requires Immediate Evaluation for Secondary Causes Before Fit-to-Work Clearance

This patient cannot be cleared for work until secondary headache causes are excluded, given the recent change in headache character, new-onset dizziness, and tremor-like sensation that deviate from typical migraine presentation. 1, 2

Most Likely Diagnosis

Primary diagnosis: Migraine without aura, based on:

• Unilateral temporal location with throbbing character 1
• Duration >4 hours with moderate intensity (5/10) 3
• Aggravation by routine activity (computer work) 1
• Partial response to simple analgesics 3

However, several atypical features mandate exclusion of secondary causes:

• New-onset "earthquake-like tremor" sensation (not typical migraine-associated dizziness) 2, 4
• Recent change from continuous sharp to throbbing character within 24 hours 5
• Temporal relationship to new eyeglass prescription 2 months ago (possible uncorrected refractive error contributing, but insufficient to explain acute change) 3

Red Flags Requiring Immediate Investigation

This patient has concerning features that warrant neuroimaging before any clearance: 1, 2

• New headache pattern in a young adult (recent onset, changing character) 5, 6
• Associated neurological symptom (tremor-like sensation/dizziness) that is unexplained 1, 6
• Positional component (worse in mornings, suggesting possible intracranial pressure changes) 2, 5

The American College of Neurology recommends immediate MRI or CT when headaches show rapidly increasing frequency or severity, or are accompanied by abnormal neurologic symptoms. 1 While vital signs are normal and physical exam is "essentially normal," the subjective tremor-like sensation constitutes a neurological symptom requiring evaluation. 2, 6

Immediate Next Steps (Before Work Clearance)

1. Urgent Neuroimaging

• Brain MRI with MR venography is the preferred initial study 2
• Excludes cerebral venous sinus thrombosis (can present with positional headache in young adults) 2
• Excludes idiopathic intracranial hypertension (relevant given visual prescription change and morning worsening) 3, 2
• Excludes structural lesions or mass effect 1, 2

2. Ophthalmologic Re-evaluation

• Verify new prescription is correct (astigmatism correction errors can cause headache but not tremor/dizziness) 3
• Fundoscopic examination for papilledema (signs of increased intracranial pressure) 3, 6

3. If Imaging is Normal, Consider:

• Lumbar puncture if suspicion remains high for increased intracranial pressure or infection 2
• Formal neurological examination to document any subtle findings 6

Acute Management (After Secondary Causes Excluded)

First-Line Treatment

NSAIDs are the appropriate first-line therapy for this mild-to-moderate migraine: 3, 1

• Naproxen sodium 500-825 mg at headache onset 1
• OR Ibuprofen 400-800 mg 3
• OR Aspirin 650-1000 mg + acetaminophen + caffeine combination 3

Paracetamol alone is inadequate – this patient already tried it with only partial relief (5/10 to 2/10), confirming it should not be continued as monotherapy. 3

Second-Line Treatment (If NSAIDs Fail)

Triptans should be prescribed if NSAIDs provide inadequate relief: 3, 1

• Sumatriptan, rizatriptan, or zolmitriptan 3
• Take early when headache is still mild for maximum efficacy 3
• Can combine with fast-acting NSAIDs to prevent relapse 3

Adjunctive Therapy

For associated dizziness/nausea (if present during attacks): 3

• Metoclopramide 10-20 mg orally 3, 2
• OR Prochlorperazine 25 mg 2

Critical Medication Overuse Prevention

Limit acute medication use to ≤2 days per week (≤10 days per month) to prevent medication-overuse headache. 3, 1 This patient is currently using paracetamol, which if used >15 days/month for >3 months can cause rebound headaches. 3

Preventive Therapy Consideration

This patient does NOT yet meet criteria for preventive therapy based on current presentation (single episode, 1 day duration). 3 Preventive therapy is indicated when: 3, 1

• ≥2 migraine attacks per month causing disability ≥3 days/month 3
• OR acute medication use >2 days per week 3, 1
• OR failure of acute treatments 3

If attacks become recurrent, first-line preventive options include propranolol 80-160 mg daily. 1

Fit-to-Work Clearance Decision

CANNOT clear for work until:

1. Neuroimaging completed and reviewed (normal) 1, 2
2. Secondary causes definitively excluded 2, 4
3. Current headache resolved or controlled to ≤2/10 3
4. No persistent neurological symptoms (tremor/dizziness resolved) 2, 6

Once cleared, provide:

• Written migraine action plan with appropriate acute medications 3
• Instructions to avoid triggers (sleep deprivation, prolonged screen time) 3
• Headache diary to track frequency and medication use 3
• Return precautions for worsening symptoms or new neurological signs 1, 6

Follow-Up

Re-evaluate in 2-3 months to assess: 1

• Attack frequency and severity 1
• Medication use patterns (to prevent overuse) 3, 1
• Need for preventive therapy if attacks become recurrent 3, 1
• Headache diary review 3