What is the recommended management for hemicrania (half-sided headache) prophylaxis?

Management of Hemicrania Prophylaxis

Indomethacin is the mainstay of prophylactic treatment for hemicrania continua (HC) and chronic paroxysmal hemicrania (CPH), with complete and sustained relief of symptoms at doses ranging from 50-300 mg/day. 1, 2

First-Line Treatment

• Indomethacin provides complete relief of symptoms in hemicrania continua and chronic paroxysmal hemicrania, typically within 3 days of treatment initiation at an average dose of 84 mg/day 1
• The response to indomethacin is so characteristic that it is considered a diagnostic criterion for these conditions 3
• With prolonged treatment, 42% of patients may experience a decrease of up to 60% in the dose required to maintain a pain-free state 1
• Typical maintenance doses range from 50-300 mg/day, with dosing individualized based on symptom control 2

Alternative Options for Patients Who Cannot Tolerate Indomethacin

For patients who experience side effects from indomethacin or have contraindications to its use:

• COX-2 Inhibitors:

  • Celecoxib (200-400 mg/day) has shown efficacy as an alternative with potentially fewer gastrointestinal side effects 2, 4

• Calcium Channel Blockers:

  • Verapamil has demonstrated effectiveness as a second-line agent for chronic paroxysmal hemicrania 3

• Anticonvulsants:

  • Gabapentin (600-3,600 mg/day) has shown promising results for hemicrania continua 2
  • Topiramate (100 mg twice daily) is an effective alternative option 2
  • Pregabalin (150 mg/day) may allow for reduction of indomethacin dosage when used in combination therapy 5

• Other NSAIDs:

  • Piroxicam and acetylsalicylic acid have shown some efficacy as alternatives 4, 3

Monitoring and Management of Side Effects

• Gastrointestinal side effects are the most common adverse events with indomethacin treatment (23% of patients) 1
• Consider prophylactic use of H2-blockers (e.g., ranitidine) or proton pump inhibitors to prevent gastrointestinal complications 1
• Regular monitoring for potential adverse effects is essential, particularly with long-term use 1

Combination Therapy Approaches

• For patients who cannot tolerate full-dose indomethacin, consider combination therapy:
  • Low-dose indomethacin (25 mg/day) plus pregabalin (150 mg/day) has been reported effective in maintaining symptom control while minimizing side effects 5

Important Clinical Considerations

• An adequate trial period of 2-3 months is recommended before determining efficacy of preventive treatments 6
• Consider tapering or discontinuing treatment after a period of stability to determine if prophylaxis is still needed 6
• Use headache diaries to track attack frequency, severity, duration, and treatment response 6

Common Pitfalls to Avoid

• Inadequate dosing of indomethacin (doses below 50 mg/day may be insufficient for many patients) 2
• Premature discontinuation of therapy before adequate trial period (at least 2-3 months) 6
• Failure to address medication side effects, which may lead to poor adherence 1
• Not recognizing medication overuse headache from frequent use of acute medications 6