Pharmacology
Headaches
Case Study
Patient Profile
Name: Javier
Age: 40 years old
Gender: male
Current Medications
None
History of Present Illness
Javier, a 40-year-old man, presents with concern for a two-week history of non-pulsatile waxing and waning headaches around the left eye, each lasting about 20 minutes and occurring daily. He feels like someone is stabbing him in the eye. He had headaches like this a few years ago that lasted every day for months but they eventually went away. When he woke up this morning and developed the headache, he called and was very glad to be able to come right over to the office to be seen. He does not take anything because they go away in about 20 to 60 minutes and does not see the point in taking medication. He is concerned because they keep coming back. “When the headache happens, my left eye runs like I am crying, and my nose runs too.” Denies visual changes, nausea, vomiting, lack of ability to speak, slurred speech, or weakness.
Relevant Assessment
Afebrile, hemodynamically stable, well oxygenated on room air. Visibly distressed, room darkened by nurse, puts head in hands.
HEENT: Atraumatic. Extra ocular movements intact (EOMI). Ears: External ears normal. Tympanic membranes intact, pearly grey, bony landmarks and cone of light visible bilaterally. No erythema, injection, bulging or retractions. Nose: Patent. No erythema, septal deviation, polys, or enlarged turbinates. Throat: Tonsils 1+ bilaterally. No erythema, exudates.
Neurological: Alert and oriented to person, place, time, and purpose. Cranial nerves II-XII intact. PERRLA. Romberg is negative. Gait steady. No pronator drift. Deep tendon reflexes: 2+ patellar and biceps bilaterally.
No other expanded review of system (subjective data) or examination (objective data) has an impact on the diagnosis reviewed in this case.
Differentials
Cluster headache, tension headache, migraine headache, secondary headache (metabolic disorder or intracranial mass/lesion)
Diagnosis
Cluster headache
Diagnostic Testing
MRI at initial diagnosis to rule out secondary cause of headache (structural brain lesion)
Referrals
None at this time; neurology if current treatment plan does not help
Patient/Provider Collaborative Goals
Javier will experience relief from headaches by time of planned follow-up.
Therapeutic Interventions
- Describe a first-line pharmacologic treatment: Include drug name, dose and formulation, frequency, and length of treatment at this dose.
Answer:
One option is abortive treatment; high-dose O2 therapy in the office; 7-10L/minute oxygen via a non-rebreather for 15-20 minutes.
Prophylaxis: Prednisone 50 mg tablets, take two tablets daily for three days; then taper the dose down by 10 mg every three days until finished.- Drug Mechanism of Action:
Answer:
Prednisone has an anti-inflammatory effect by suppressing migration of polymorphonuclear leukocytes and reversing increased capillarypermeability
- Contraindications if applicable:
Answer:
Hypersensitivity to prednisone or any components of the formulation and in patients with systemic fungal infections.
- Drug Mechanism of Action:
- Therapeutic advisement and monitoring: (include any specific instructions that apply, such as when to take the medication, if there are foods to avoid, storage issues, etc; include what laboratory/other (i.e., EKG) test monitoring to expect and how often and monitoring for adverse effects both common and serious)
Answer:
Specific Instructions: Patients should be advised to report any serious adverse effects listed below. Additionally, if patients smoke, drink alcohol, or consume other substances such as illicit drugs, they should be encouraged to stop as these things may trigger headaches. Moreover, consider if certain foods or prescribed or over-the-counter medications are a cause of headaches. Having the patient keep a log of ingestions and timing related to headache onset can be helpful in identifying headache triggers.
- Therapeutic Monitoring: Nurse practitioners should consider the following based upon the patient’s risk factors. Monitoring may include blood pressure, weight, glucose, electrolytes, creatine kinase, symptoms and signs of infection, or gastrointestinal bleeding.
- Monitor Side/Adverse Effects: There are a variety of side/adverse effects across all body systems, the most common of which are jitteriness, insomnia, and elevated blood glucose.
- Serious adverse effects are unlikely but possible at this prescribed dose and duration however higher and longer durations require closer monitoring for the following:
- Adrenal Suppression: The risk of adrenal suppression is greater for elderly patients and for those with a higher body mass index (BMI) and systemic glucocorticoids (versus topical). This condition is from inadequate stimulation of the adrenal glands. Discontinuation of the glucocorticoid/prednisone therapy is the treatment. Symptoms may persist for six months to a year. A severe form is an adrenal crisis which may lead to life-threatening hypotension.
- Cardiovascular Effects: Hypertension, dyslipidemia, fluid retention, electrolyte disturbances, and arrhythmias.
- Central Nervous System and Psychiatric: Agitation, anxiety, distractibility, fear, hypomania, insomnia, irritability, lethargy, labile mood, mania, pressured speech, restlessness, tearfulness, apathy, and depression. These adverse effects may require discontinuing glucocorticoid/prednisone therapy.
- Cushingoid Features/Cushing Syndrome: Symptoms and signs include truncal obesity, facial adipose tissue, dorsocervical adipose tissue, fluid retention, and weight gain. Risk is greater with a higher BMI.
- Gastrointestinal Effects: Problems include peptic ulcer, dyspepsia, gastritis, abdominal distention, and ulcerative esophagitis. Risk factors include concomitant use of non-steroidal anti-inflammatory drugs, hospitalized patients, and recent use of corticosteroids.
- Hyperglycemia: Glucocorticoid/prednisone therapy may instigate new onset hyperglycemia or exacerbation of diabetes mellitus.
- Infection: Extended use of glucocorticoid/prednisone may foster infections including Pneumocystis jirovecii pneumonia (PJP), herpes zoster, tuberculosis, and other bacterial infections. The discontinuation of the treatment will reverse the susceptibility to infection.
- Neuromuscular and Skeletal Effects: Problems may include osteoporosis, vertebral compression fractures, myopathy, and osteonecrosis. Risk factors include advanced age, higher BMI, low bone mineral T score, endocrine disorders, alcohol or tobacco use, female gender, Caucasian race, fall history, fracture history, malabsorption disorders, presence of malignancy, and inflammatory conditions.
- Ocular Effects: Increased intraocular pressure, glaucoma, and subcapsular posterior cataract. These effects may be permanent. Risk factors include ocular dosing, family history of open angle glaucoma, type I diabetes mellitus, myopia, pseudophakia, history of vitrectomy, connective tissue disorders, advanced age, or those younger than six years.
- Planned follow-up should consider adverse effect monitoring, dose adjustment considerations, and decisions about continuing versus discontinuing. In this case, planned follow-up would be:
Answer:
Office visit in one week.
Review Questions
Click the arrow to expand the section and view the correct answers.
- Headaches that are severe, unilateral, start around one eye, last 30 minutes, and have associated ipsilateral lacrimation, nasal congestion, rhinorrhea, pallor, sweating, and Horner syndrome, may be treated with which of the following?
- Lidocaine topically (patch)
- Oxycodone by mouth
- Propranolol by mouth
- Oxygen, prednisone by mouth, verapamil by mouth
Answer:
D. Oxygen, prednisone by mouth, verapamil by mouth
Feedback: The scenario describes a cluster headache. Treatments for cluster headaches include supplemental oxygen, prednisone, and verapamil. Other options include galcanezumab, lithium, topiramate, and greater occipital nerve block. Treatment of an acute cluster headache includes supplemental oxygen if available or triptans if oxygen is not available. Triptans may include sumatriptan (Imitrex) or zolmitriptan (Zomig)
- A patient describes her headache as bilateral bandlike pressure/tightness that comes and goes, lasts for up to five days and when present, interferes with her activities of daily living. She has no other symptoms. She can be treated with which of the following?
- Amitriptyline
- Oxycodone
- Lidocaine topically (patch)
- Supplemental oxygen, prednisone by mouth, verapamil by mouth
Answer:
A. Amitriptyline
Feedback: This scenario describes a tension headache. Acute treatment of tension headaches includes non-steroidal anti-inflammatory drugs like ibuprofen (Advil, Motril), naproxen (Aleve), aspirin, or other analgesic-like acetaminophen (Tylenol). Prevention for tension type headaches include trigger avoidance, stress management, good sleep hygiene, good nutrition, exercise, biofeedback with relaxation therapy, or cognitive behavioral therapy. Other preventive treatments for recalcitrant cases include tricyclic antidepressants like amitriptyline, other classes of anti-depressants like selective serotonin reuptake inhibitors, or selective serotonin norepinephrine reuptake inhibitors, anti-seizure medications, or botulinum injections.
- You see a patient who is experiencing unilateral gradual onset, progressively worsening throbbing type headaches that last between four and 72 hours. There is reported associated nausea, vomiting, photophobia and phonophobia. What could this headache be treated with?
- Oxycodone
- Sumatriptan (Imitrex)
- Supplemental oxygen, prednisone by mouth, verapamil by mouth
- Lidocaine topically (patch)
Answer:
B. Sumatriptan (Imitrex)
Feedback: Acute abortive treatment for migraine headaches may include non-steroidal anti-inflammatory drugs like ibuprofen (Advil, Motril) or naproxen (Aleve). If those are ineffective, triptans are the next step, including sumatriptan (Imitrex), zolmitriptan (Zomig), rizatriptan (Maxalt), and others. Which triptan to use depends on the pharmacokinetic and pharmacodynamic profile in addition to the formulary for the patient’s insurance/cost. Preventive treatments include beta blockers (metoprolol, propranolol), antidepressants (tricyclic: amitriptyline; serotonin norepinephrine reuptake inhibitors: venlafaxine), anti-seizure medications (topiramate), and calcitonin gene-related peptide (CGRP) antagonists (erenumab, fremanezumab, galcanezumab, eptinezumab, atogepant, rimegepant).
- Which of the following are contraindications for use of non-steroidal anti-inflammatory medications for headache disorder (Select all that apply):
- Creatinine clearance ≤ 30 mL/minute (severely reduced renal function)
- Creatinine clearance ≤ 60 mL/minute (mildly reduced renal function)
- Creatinine clearance ≥ 60 mL/minute (normal renal function)
- History of a stroke
- History of myocardial infarction
- History of migraine headache
- History of gastrointestinal bleeding
- History of bowel obstruction
Answer:
A. Creatinine clearance ≤ 30 mL/minute; D. History of stroke; E. History of myocardial infarction; G. History of gastrointestinal bleeding
Feedback: Non-steroidal anti-inflammatory drugs like ibuprofen and naproxen should be avoided in patients with severe renal impairment, significant risk factors for or history of stroke or myocardial infarction, and history of gastrointestinal bleeding.
- Which patient should not take oral sumatriptan (Imitrex) for treatment of a headache disorder?
- A patient with creatine clearance of ≥ 60 mL/minute
- A patient with gastroenteritis and unable to keep fluids down
- A patient with long standing severe alcoholism
- A patient with long standing history of migraine or cluster headaches not responsive to other medications
Answer:
C. A patient with long standing severe alcoholism
Feedback: Triptans undergo significant first pass hepatic metabolism; therefore, oral preparations should be avoided in patients with moderate to severe liver impairment to avoid toxic levels of the medication. Other formulations like intranasal or intramuscular do not undergo this first pass hepatic metabolism. Therefore, these may be used in mild hepatic impairment but are still not recommended in moderate to severe impairment.
- Patients with multiple cardiovascular risk factors should have an EKG prior to use of triptans. (True or False)
- True
- False
Answer:
A. True
Feedback: Patients with multiple cardiovascular risk factors should have an EKG prior to use of triptans. Serious cardiovascular events can occur shortly after a first dose of triptan therapy including, but not limited to, transient cardiac ischemia, myocardial infarction, and cardiopulmonary arrest. Patients should be evaluated for cardiovascular risk factors with vital signs, atherosclerotic cardiovascular disease risk score, and EKG prior to triptan therapy.
- When considering the use of prednisone for cluster headache treatment, which patient should NOT have prednisone treatment?
- A patient with current bacterial conjunctivitis
- A patient with current viral conjunctivitis
- A patient with current allergic conjunctivitis
- A patient with current herpes simplex ocular infection
Answer:
D. A patient with current herpes simplex ocular infection
Feedback: Patients with herpes simplex ocular infections should not have treatment with corticosteroids (prednisone) due to risk of corneal perforation.
- Migraine headache treatment works best if the medication intervention is taken within the first 60 minutes of the onset of the headache. (True or False)
- True
- False
Answer:
B. False
Feedback: Migraine headache treatment works best if the medication intervention is taken within the first 15 minutes of the onset of the headache
References
Condina Leik, M. T. (2025). Nervous system review. In FNP Certification Intensive Review (pp. 275–295). Springer Publishing.
International Headache Society. (2021). Headache attributed to a substance or its withdrawal. International Classification of Headache Disorders (3rd ed.). https://ichd-3.org/8-headache-attributed-to-a-substance-or-its-withdrawal/
Peng, K. P. & Burish, M. J. (2023). Management of cluster headache: Treatments and their mechanisms. Cephalalgia. 43(8). doi.org/10.1177/03331024231196808
Rosenthal, L. D., & Burchum, J. R. (2026). Drugs for headache. In Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (3rd ed., pp. 192–199). Elsevier.
Up To Date® (2025). Prednisone: Drug information. Lexidrug. Retrieved June 11, 2025 from https://www.uptodate.com/contents/prednisone-drug-information
an artificial intraocular lens, usually due to cataract surgery
removal of vitreous humor to allow access to the retina for eye surgical procedures
same side
A condition with symptoms including drooping of the upper eyelid, constricted pupil, and decreased sweating on one side of the face. This is the result of damage to the sympathetic nerves of the face. It can be due to headaches (migraine or cluster), brain or spinal cord injury, neck or soft tissue pathology (mass), or carotid artery dissection.
