What is the treatment for paroxysmal hemicrania?

Treatment for Paroxysmal Hemicrania

Indomethacin is the treatment of choice for paroxysmal hemicrania, with complete symptom relief serving as both a therapeutic intervention and diagnostic criterion. 1, 2

First-Line Treatment

• Indomethacin should be initiated at a low dose (typically 25mg three times daily) and titrated up to achieve complete pain relief, with most patients responding to 75-150mg daily 3
• Complete pain relief typically occurs within 3 days of starting appropriate indomethacin dosing 3
• Long-term follow-up shows that 42% of patients can reduce their indomethacin dose by up to 60% over time while maintaining pain control 3
• Indomethacin should be taken at the lowest effective dose to minimize side effects 2

Management of Side Effects

• Gastrointestinal side effects are the most common adverse events with indomethacin therapy (occurring in approximately 23% of patients) 3
• Co-administration of ranitidine or other gastric protectants can effectively manage gastrointestinal side effects 3
• Taking indomethacin with food can reduce gastrointestinal irritation, though this may slightly reduce absorption 1

Alternative Treatments for Indomethacin-Intolerant Patients

When indomethacin cannot be tolerated due to side effects, consider these alternatives:

• Verapamil has shown efficacy as a second-line agent for paroxysmal hemicrania 4
• Other NSAIDs that may be effective include:
  • Acetylsalicylic acid (aspirin) 4
  • Piroxicam for both acute and prolonged treatment 1
  • Celecoxib as an alternative with potentially fewer gastrointestinal side effects 1
• Topiramate and gabapentin have shown some efficacy in case reports 1

Treatments to Avoid

• Carbamazepine has not shown significant efficacy in paroxysmal hemicrania 4
• Oxygen therapy, which is effective in cluster headache, does not show significant benefit in paroxysmal hemicrania 4

Monitoring and Follow-up

• Regular follow-up is recommended to assess treatment response and adjust indomethacin dosing 3
• Brain MRI with specific pituitary views is recommended at diagnosis to rule out secondary causes 2
• Long-term indomethacin treatment has shown a good safety and tolerability profile in studies with average follow-up of 3.8 years 3

Emerging Therapies

• Noninvasive vagus nerve stimulation has recently shown promise as an indomethacin-sparing therapy and may provide headache control in some patients 2
• This approach may be particularly valuable for patients who cannot tolerate long-term indomethacin therapy 2

Important Clinical Considerations

• The absolute response to indomethacin is so characteristic that it serves as a diagnostic criterion for paroxysmal hemicrania 1, 2
• If a suspected paroxysmal hemicrania does not respond completely to adequate doses of indomethacin, reconsider the diagnosis 5
• For any primary headache disorder that does not respond to standard therapy, a brief therapeutic trial of indomethacin may be warranted 5