Indomethacin Dosing for Hemicrania Continua
The recommended dose of indomethacin for hemicrania continua is 75-150 mg daily, with an initial dose of 25 mg three times daily that can be titrated up as needed for symptom control. 1
Dosing Protocol
- Start with indomethacin 25 mg three times daily (75 mg/day) as the initial therapeutic dose 1
- Complete response (pain freedom) typically occurs within 3 days of starting treatment at appropriate doses 1
- If needed, increase dose gradually up to 150 mg/day (divided doses) for complete pain relief 1
- Once pain control is established, attempt to reduce the dose by up to 60% for maintenance therapy, as many patients can maintain pain freedom at lower doses over time 1
Clinical Considerations
- Indomethacin response is considered diagnostic for hemicrania continua - complete pain relief confirms the diagnosis 2
- The average effective dose in long-term treatment studies is 84 ± 32 mg/day 1
- Long-term studies show good safety and tolerability profile with proper monitoring 1
- Approximately 42% of patients can reduce their dose by up to 60% after initial control is achieved 1
Side Effects and Management
- Gastrointestinal side effects are most common (23% of patients) 1
- Consider gastric protection with ranitidine or proton pump inhibitors for patients on long-term therapy 1
- Monitor for potential NSAID-related complications including:
- Gastric ulceration
- Renal function impairment
- Cardiovascular effects with prolonged use 3
Alternative Options for Patients Unable to Tolerate Indomethacin
If indomethacin cannot be tolerated at effective doses:
- Consider combination therapy with low-dose indomethacin (25 mg/day) plus pregabalin (150 mg/day) 4
- Alternative monotherapies with reported efficacy include:
Special Considerations
- Hemicrania continua is often misdiagnosed - the average time to correct diagnosis is 12 years 3
- All patients with continuous unilateral headache should receive an indomethacin trial early in treatment 2
- Short-term indomethacin may have additional benefit in reducing intracranial pressure, which may contribute to its efficacy 5