Chronic daily bilateral headache responsive to indomethacin

Indomethacin is known to be specifically effective for chronic paroxysmal hemicrania, episodic paroxysmal hemicrania, and hemicrania continua. Different forms of idiopathic stabbing headaches have also been responsive to indomethacin, but less consistently than the others. Two cases of indomethacin-responsive headache are reported. One patient presented with what appeared to be new-onset, chronic, daily, bilateral headache aggravated by coughing. Both the chronic daily headache and the exacerbations induced by coughing were suppressed with indomethacin therapy. The second patient experienced hemicrania continua responsive to indomethacin, and the response persisted even when the headache evolved into bilateral continuous pain. There may be other idiopathic primary headache disorders that are peculiarly responsive to indomethacin. When any primary headache disorder does not respond to standard therapy, a brief therapeutic trial of indomethacin is warranted.     

Hemicrania continua: who responds to indomethacin?

Hemicrania continua (HC) is a primary headache disorder characterized by a continuous, moderate to severe, unilateral headache and defined by its absolute responsiveness to indomethacin. However, some patients with the clinical phenotype of HC do not respond to indomethacin. We reviewed the records of 192 patients with the putative diagnosis of HC and divided them into groups based on their headaches' response to indomethacin. They were compared for age, gender, presence or absence of specific autonomic symptoms, medication overuse, rapidity of headache onset, and whether or not the headaches met criteria for migraine when severe. Forty-three patients had an absolute response and 122 patients did not respond to adequate doses of indomethacin. The two groups did not differ significantly in terms of age, sex, presence of rapid-onset headache, or medication overuse. Autonomic symptoms, based on a questionnaire, did not predict response. Eighteen patients could not complete a trial of indomethacin due to adverse events. Nine patients could not be included in the HC group despite improvement with indomethacin: one patient probably had primary cough headache, another paroxysmal hemicrania; three patients improved but it was uncertain if they were absolutely pain free, and four patients dramatically improved but still had a baseline headache. We found no statistically significant differences between patients who did and did not respond to indomethacin. All patients with continuous, unilateral headache should receive an adequate trial of indomethacin. Most patients with unilateral headache suggestive of HC did not respond to indomethacin.     

Hemicrania continua with aura

Hemicrania continua is a primary headache disorder that is characterized by a continuous unilateral headache of moderate severity, exacerbations of severe pain and complete responsiveness to indomethacin. We report four patients with a unique variant of hemicrania continua: visual auras that precede or accompany the pain exacerbations.     

Hemicrania Continua and Symptomatic Medication Overuse

SYNOPSIS
Hemicrania continua (HC) is a rare, strictly unilateral, non-paroxysmal headache disorder characterized by its absolute responsiveness to indomethacin. The pain is usually moderate in intensity and frequently associated with a superimposed"jabs and jolts" headache.
We report two cases of HC which presented as chronic daily headache (CDH) with abortive medication overuse.
CDH can be due to transformed migraine (TM), new daily persistent headache (NDPH), chronic tension-type headache, and HC. All can be unilateral, and all can be associated with medication overuse. Our two cases meet the criteria for HC based on indomethacin responsiveness. One meets the criteria for TM, the other NDPH. Is HC a distinct disorder, or a subset of these other disorders? CDH with medication overuse includes in its differential diagnosis HC.     

LASH: a syndrome of long-lasting autonomic symptoms with hemicrania (A new indomethacin- responsive headache)

A patient presented with a unique, stereotypical, episodic headache disorder marked by long-lasting autonomic symptoms with associated hemicrania (LASH). The autonomic symptoms clearly overshadowed the headache as the major component of the syndrome. Indomethacin controlled both the autonomic symptoms and the headache, suggesting that this is a new type of indomethacin-responsive headache. It may also complete the indomethacin-responsive headache spectrum.     

Primary stabbing headache in a headache clinic

Primary stabbing headache (PSH) is a short-lasting but troublesome headache disorder which has been known for several decades. We surveyed and registered consecutive patients with PSH in a headache clinic in Taiwan. A total of 80 patients (24 M/56 F, 53.2 +/- 16.2 years) were enrolled in our study. Migraine was reported in 20 (25%) patients and was less common in those with PSH onset at >50 years than those with onset at <50 years (14% vs. 38%, P = 0.02). The headache was unilateral in 59% of the patients and always in a fixed area in 36%. The head pain frequently involved extratrigeminal regions (70%) and in 30 patients (38%) was accompanied by jolts, i.e. head or body movements. Indomethacin was effective (74%) in patients who received it. Our study showed primary stabbing headache was a common and easily treated headache disorder in headache clinic. However, 70% of our patients could not fulfil criterion A 'exclusively or predominantly in the distribution of the first division of the trigeminal nerve' and 15% could not fulfil criterion C 'no accompanying symptoms' of the International Classification of Headache Disorders-II criteria proposed for PSH.     

Remitting form of hemicrania continua: two new cases exhibiting one unusual autonomic feature

Hemicrania continua (HC) is an uncommon, primary headache disorder characterized by a continuous, strictly unilateral headache of moderate intensity with superimposed exacerbations of more severe pain and accompanying autonomic features. Whereas in the majority of HC patients the headache is continuous and without pain-free intervals, we report two new cases of the rare remitting form of HC. One patient described unusual olfactory sensation during episodes of exacerbation, which we classify as an olfactory aura.     

Hemicrania continua evolving from episodic paroxysmal hemicrania

A 45-year-old woman, who had been diagnosed in our unit with episodic paroxysmal hemicrania, was seen 2 years later for ipsilateral hemicrania continua in remitting form. Both types of headache had a complete response to indomethacin and did not occur simultaneously. The patient had a previous history of episodic moderate headaches that met criteria for probable migraine without aura and also had a family history of headache. The clinical course in this case suggests a pathogenic relationship between both types of primary headache.     

Prophylaxis of hemicrania continua: two new cases effectively treated with topiramate

Hemicrania continua (HC) is an uncommon and under-recognized primary headache disorder characterized by a strictly unilateral continuous headache of moderate intensity with possible exacerbations and associated with ipsilateral autonomic features. HC has generally a prompt and enduring response to indomethacin although 25% to 50% of treated patients develop gastrointestinal side effects. These cases pose a difficult management challenge as no other drug is consistently effective in HC. Recently 2 HC patients responsive to topiramate treatment have been reported. Here we describe 2 more patients effectively treated with topiramate. Neither reported any side effects and one had persisting response for 6 months after drug withdrawal.     

Hemicrania continua: a third case in which attacks alternate sides

Hemicrania continua (HC) is an uncommon, primary headache disorder characterized by a continuous unilateral headache of moderate intensity with superimposed exacerbations of more severe pain. HC exists in two temporal subtypes, a continuous form in which headaches persist continuously without remission periods, and a less common remitting form in which bouts of continuous headaches are separated by pain-free remissions. There have been more than 100 prior reports of HC; in the majority of which the headache is strictly unilateral and without side shift. We now report the third patient in whom headaches alternated sides during different attacks.     

Hemicrania Continua–Like Headache With Leprosy: Casual or Causal Association?

Hemicrania continua is a strictly unilateral, moderate to severe, continuous, indomethacin-responsive primary headache disorder with ipsilateral autonomic cranial symptoms at the time of exacerbations. We describe a 30-year-old woman with a 4-month history of indomethacin-responsive hemicrania continua–like headache and one-month history of mononeuritis multiplex due to leprosy. Indomethacin was successfully weaned off after completion of antileprotic therapy.     

Hemicrania continua: comparison between two different classification systems

Hemicrania continua is an uncommon primary headache disorder. This study of nine patients compares two different classification systems, proposed by Pareja et al. and Goadsby and Lipton. Although it seems logical to position the nosologic status of hemicrania continua under group 3 of the International Headache Society Classification, as proposed by Pareja et al., the Goadsby and Lipton classification is more clinically useful and should be included in future International Headache Society reclassification.     

Hemicrania continua responds to cyclooxygenase-2 inhibitors

BACKGROUND: Hemicrania continua is a primary headache disorder defined by its absolute responsiveness to indomethacin. We report the treatment response to two cyclooxygenase-2 inhibitors, celecoxib and rofecoxib, in a series of patients with hemicrania continua. METHODS: Fourteen patients were treated, 9 with rofecoxib and 5 with celecoxib. RESULTS: Three patients in each group had a complete response to treatment. CONCLUSION: The cyclooxygenase-2 inhibitors may represent an alternative to indomethacin in the treatment of hemicrania continua. Their mechanism of action for this potential indication is unknown.     

Hemicrania Continua‐Like Headache Related to Transdermal Nitroglycerine Therapy

Several cases of symptomatic hemicrania continua (HC) have been reported. A 66‐year‐old man, suffering from migraine without aura, presented with a four month history of a new headache fulfilling the ICHD 3beta clinical criteria for HC. HC onset was strictly related to the use of transdermal nitroglycerine patch (TNP). In agreement with the cardiologist, TNP was discontinued and the headache promptly disappeared; symptoms reappeared within 6‐12 hours after nitroglycerine reintroduction. After permanent discontinuation of TNP, headache disappeared at one year follow‐up. To the best of our knowledge, this is the first report of the occurrence of an HC‐like headache related to TNP.     

Case Report: Shortest Course of Pediatric Paroxysmal Hemicrania

Paroxysmal hemicrania (PH) is a rare primary headache disorder, especially among children. We describe herein a case with the shortest course of pediatric PH among previously reported cases, and the first case report of Japanese pediatric PH. An 11-year-old boy was referred to our clinic by his primary care physician for a headache evaluation. He had been complaining of severe, sharp, pulsating headache for 5 days. Attacks were restricted to the left side with a duration ranging from 2 to 20 minutes, 20-30 times a day. Attacks were associated with left autonomic symptoms (conjunctival injection, lacrimation, nasal congestion, eyelid edema, and ptosis). Two days after we prescribed indomethacin at 0.9 mg/kg/day, the patient was headache free. He stopped taking indomethacin 14 days after consultation because of drug eruptions. As of the time of writing, more than 1 year later, he has experienced no recurrence of headache. This case indicates the importance of improving awareness among general doctors regarding PH in children, and of conducting further investigations about low-dose, short-term indomethacin treatment.     

Hemicrania Continua Responsive to Intravenous Methyl Prednisolone

Hemicrania continua (HC) is a strictly unilateral, continuous primary headache disorder with periodic exacerbations, usually accompanied by cranial autonomic disturbances. Exquisite and persistent effect of indomethacin is a fundamental property of HC. We report 2 patients of HC in which attacks were successfully eliminated by repeated infusion of methyl prednisolone.     

Classification of Daily and Near-Daily Headaches: Proposed Revisions to the IHS Criteria

SYNOPSIS
The International Headache Society (IHS) headache classification, while a major advance, does not adequately classify the daily and near-daily headache disorders known as chronic daily headache (CDH). We believe that chronic daily headache is a group of disorders which includes chronic tension-type headache (CTTH), transformed migraine (TM), new daily persistent headache (NDPH), and hemicrania continua (HC). We propose specific criteria for transformed migraine, new daily persistent headache, and hemicrania continua, and have modified the criteria for chronic tension-type headache.     

Evaluation for secondary causes of headache: the role of blood and urine testing

Most patients presenting for evaluation of headache meet diagnostic criteria for a benign, primary headache disorder based on history and physical examination findings alone. No further testing is needed in such cases. Additional diagnostic evaluation is needed in cases that do not meet criteria for a primary headache disorder or which are associated with unusual or worrisome features. This article will review secondary causes of headache listed in the International Classification of Headache Disorders-II in which blood and urine testing might aid in diagnosis. We offer recommendations for diagnostic evaluation when these disorders are suspected causes of headache.     

Sinus problems as a cause of headache refractoriness and migraine chronification

Sinus headache is not a diagnostic term supported by the academia, yet it appears to be understood by the general public and larger medical community. It can be considered both a primary and secondary headache disorder. As a primary headache disorder, most of the patients considered to have sinus headache indeed have migraine (migraine with sinus symptoms). Yet it is also possible that some attacks of sinus headache may represent a unique clinical phenotype of migraine or be a unique clinical entity. Potentially, primary sinus headache can chronify and be refractory through immune-mediated mechanisms or as a catalyst for migraine chronification through ineffective treatment or medication overuse and misuse. As a secondary headache disorder, sinus headache can be associated with a wide range of underlying etiologies such as infection, anatomical abnormalities, trauma, and immunological disease or sleep disorders. It is possible that these underlying pathophysiological processes generate long-standing activation of nociceptive mechanisms involved in headache and can lead to chronification and refractoriness of the headache symptomatology. This article explores some of the potential mechanisms and the available scientific studies that may explain how sinus headache can become chronic and present to the clinician as a refractory headache disorder.     

Hemicrania Continua: Beneficial Effect of Non‐Invasive Vagus Nerve Stimulation in a Patient With a Contraindication for Indomethacin

Hemicrania continua (HC) is a primary chronic headache disorder, characterized by a continuous and strictly unilateral headache, with possible cranial autonomic symptoms during episodes of pain exacerbation. The unilateral headache generally responds well to indomethacin; however, continuous indomethacin intake is often not tolerated due to severe adverse effects, like hypertension, gastrointestinal discomfort (especially if combined with aspirin), slightly increased risk of vascular events, and bronchial spasms. Therefore, alternative treatment options are desperately needed. Non‐invasive vagus nerve stimulation (nVNS) has been shown to be effective in patients with cluster headache, another trigeminal autonomic cephalalgia (TAC), with cranial parasympathetic autonomic activation during the attacks.