From the Guidelines
Treatment of hemicrania should prioritize preventive approaches, with medications such as propranolol (80 to 240 mg/d), timolol (20 to 30 mg/d), amitriptyline (30 to 150 mg/d), divalproex sodium (500 to 1500 mg/d), and sodium valproate (800 to 1500 mg/d) as first-line agents, as recommended by the Annals of Internal Medicine 1. When managing hemicrania, it's essential to consider the following key points:
- Educate patients about controlling acute attacks and preventive therapy, and engage them in formulating a management plan, as emphasized in the study 1.
- Medications with proven efficacy, such as flunarizine, lisuride, pizotifen, time-released DHE, and methysergide, may be considered, but their use should be weighed against potential adverse events 1.
- Patient input and involvement in their management are crucial, and using tools like daily flow sheets to track progress can be beneficial 1.
- The International Headache Society Classification can serve as a guide for diagnosis and treatment, as referenced in Appendix Table 1 of the study 1.
- A comprehensive treatment plan should include lifestyle modifications, such as regular sleep patterns, stress management, and trigger avoidance, to target the neurovascular mechanisms involved in headache generation.
- While the study primarily focuses on migraine, the principles of preventive treatment and patient education can be applied to hemicrania, prioritizing a patient-centered approach to manage this condition effectively.
From the Research
Treatment Options for Hemicrania
- Indomethacin is a commonly used treatment for hemicrania continua (HC) and chronic paroxysmal hemicrania (CPH), with studies showing it to be effective in providing complete and sustained relief of symptoms 2, 3.
- However, indomethacin can have significant side effects, particularly with long-term use, and may not be suitable for all patients 2, 3.
- Alternative treatments for HC include gabapentin, topiramate, cyclooxygenase-2 inhibitors, piroxicam, beta-cyclodextrin, amitriptyline, and melatonin 2, 4, 5.
- Gabapentin has been shown to be effective in reducing pain in patients with HC who are unable to tolerate indomethacin due to adverse effects 5.
- Other treatments, such as celecoxib and lamotrigine, may also be effective in managing HC and other related conditions 4.
Efficacy of Treatment Options
- A study found that prophylactic treatment with amitriptyline was effective in 66.6% of cases, while gabapentin and topiramate were effective in 20% and 10% of cases, respectively 2.
- Another study found that gabapentin was effective in reducing pain in 7 out of 9 patients with HC, with 4 patients becoming completely pain-free 5.
- Indomethacin has been shown to be effective in providing complete and sustained relief of symptoms in HC and CPH, with 84% of patients experiencing relief of symptoms within 3 days of treatment 3.
Diagnosis and Management
- Hemicrania continua is a highly misdiagnosed and underreported primary headache disorder, with a pooled mean delay of diagnosis of 8.0 ± 7.2 years 6.
- The central feature of HC is continuous background headache, with superimposed severe exacerbations 6.
- A remarkable response to indomethacin is a specific feature of HC, but a large number of patients may develop side effects due to long-term use 6.
- Various surgical interventions have been suggested for patients who are intolerant to indomethacin, but further studies are needed to define the treatment of choice for HC 6.