Indomethacin Dosing for Hemicrania Continua
For hemicrania continua, indomethacin should be initiated at 25 mg three times daily (75 mg/day) and can be titrated up to 300 mg/day as needed for symptom control, with many patients experiencing dose reduction requirements over time. 1, 2, 3
Initial Dosing and Titration
- Start with 25 mg three times daily (75 mg/day)
- If inadequate response, increase dose gradually
- Effective dose typically ranges from 50-300 mg/day 3
- Complete pain relief usually occurs within 3 days of reaching the effective dose 2
Long-term Management
- After establishing control, attempt to find the minimum effective dose
- 42% of patients experience a decrease of up to 60% in the initial required dose over time 2
- Maintenance doses should be continued indefinitely as hemicrania continua is a chronic condition
Combination Therapy
- For patients with gastrointestinal side effects, consider adding:
Monitoring and Side Effects
- Monitor for gastrointestinal side effects (most common adverse events)
- Watch for potential dose-related de novo headaches 5
- No major side effects have been observed in long-term use (average follow-up of 3.8 years) 2
Alternative Options
If indomethacin is not tolerated or contraindicated:
- Gabapentin (600-3,600 mg/day)
- Topiramate (100 mg twice daily)
- Celecoxib (200-400 mg/day) 3
Important Clinical Pearls
- Complete response to indomethacin is a diagnostic criterion for hemicrania continua
- Failure to respond to adequate indomethacin trial should prompt reconsideration of diagnosis
- Long-term indomethacin treatment has shown good safety and tolerability profile 2
- Lowest effective dose should be maintained to minimize side effects while controlling symptoms
Cautions
- Indomethacin may rarely induce de novo headaches at higher doses 5
- NSAIDs including indomethacin require caution with potential gastric, renal, and cardiovascular side effects
- Consider gastroprotection with long-term use