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Chronic Paroxysmal Hemicrania Clinical Presentation

  • Author: Manish K Singh, MD; more...
Updated: Dec 08, 2014


The pain in chronic paroxysmal hemicrania (CPH) is unilateral, always affects the same side, and is generally oculofrontotemporal in location. The literature does contain reports of a few unusual cases; for example, patients with bilateral symptoms and a possible shift in the side of the headache when the CPH progresses from the nonchronic to the chronic stage.

The pain is usually most severe in the oculotemporal area, the forehead, and above or behind the ear. Occasionally, pain can radiate and involve the ipsilateral shoulder, arm, and neck.

Headache can develop at any time in patients with CPH, in contrast to CH, in which the headache usually occurs at night.

During severe attacks, excruciating pain that is throbbing, boring, pulsating, or clawlike in character has been described. In contrast to patients with CH, patients with CPH usually sit quietly or may curl up in bed between attacks.

The attack frequency usually is 10-20 attacks daily, but it may range from 2-40 attacks daily. Attacks usually last 2-25 minutes, but they may last as long as 60 minutes. In a prospective study, mean attack duration was 13 minutes (range 3-46 min). In a retrospective study, the mean duration of attacks was 21 minutes (range 2-120 min).

CPH can be triggered by various stimuli, including neck movement, external pressure to the neck, or other factors.

CPH attacks are accompanied by autonomic symptoms, mostly on the same side as the pain, such as red eyes, tearing, nasal congestion, and, sometimes, rhinorrhea. Occasionally, photophobia may be present. Gastrointestinal symptoms are very rare.

Recognizing the various stages and different patterns of CPH is important. For example, during severe, frequent attacks, patients may describe a constant headache or persisting tenderness on the symptomatic side.


Physical Examination

The pain is severe in patients with CPH, and attacks are associated with autonomic features, such as the following:

  • Lacrimation - 62%
  • Conjunctival injection - 36%
  • Ipsilateral nasal congestion - 42%
  • Rhinorrhea - 36%
  • Eyelid edema - 33%

Lacrimation may occur bilaterally but is always more marked on the symptomatic side. Occasionally, mild ipsilateral miosis may be observed during attacks.

Patients with CPH who have had dissociation in pain and autonomic features also have been described. Other points to consider in the physical examination include the following:

  • No definite evidence points to a Hornerlike syndrome, such as that described in cluster headache (CH), but mild miosis and eyelid edema that may mimic ptosis may be observed
  • Forehead sweating may increase on the ipsilateral side, and patients with generalized sweating have been reported
  • The coexistence of CPH and trigeminal neuralgia is called CPH-tic syndrome; many cases of this syndrome have been reported
  • Simultaneous occurrence of ipsilateral CH and migraine headache in patients with CPH has been reported
  • Perform a careful physical examination to evaluate pathologic secondary headache
Contributor Information and Disclosures

Manish K Singh, MD Assistant Professor, Department of Neurology, Teaching Faculty for Pain Management and Neurology Residency Program, Hahnemann University Hospital, Drexel College of Medicine; Medical Director, Neurology and Pain Management, Jersey Institute of Neuroscience

Manish K Singh, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American Headache Society, American Association of Physicians of Indian Origin, American Medical Association, American Society of Regional Anesthesia and Pain Medicine

Disclosure: Nothing to disclose.


Jashvant Patel, MBBS, MS, MD 

Jashvant Patel, MBBS, MS, MD is a member of the following medical societies: Alberta Medical Association, American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Society of Regional Anesthesia and Pain Medicine, Medical Society of the State of New York

Disclosure: Nothing to disclose.


Howard A Crystal, MD Professor, Departments of Neurology and Pathology, State University of New York Downstate; Consulting Staff, Department of Neurology, University Hospital and Kings County Hospital Center

Howard A Crystal, MD is a member of the following medical societies: American Academy of Neurology and American Neurological Association

Disclosure: Nothing to disclose.

Jorge E Mendizabal, MD Consulting Staff, Corpus Christi Neurology

Jorge E Mendizabal, MD is a member of the following medical societies: American Academy of Neurology, American Headache Society, National Stroke Association, and Stroke Council of the American Heart Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

  1. Sjaastad O, Dale I. Evidence for a new (?), treatable headache entity. Headache. 1974 Jul. 14(2):105-8. [Medline].

  2. Sjaastad O, Dale I. A new (?) Clinical headache entity "chronic paroxysmal hemicrania" 2. Acta Neurol Scand. 1976 Aug. 54(2):140-59. [Medline].

  3. Prakash S, Patell R. Paroxysmal hemicrania: an update. Curr Pain Headache Rep. 2014 Apr. 18(4):407. [Medline].

  4. The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013 Jul. 33(9):629-808. [Medline].

  5. Prakash S, Belani P, Susvirkar A, Trivedi A, Ahuja S, Patel A. Paroxysmal hemicrania: a retrospective study of a consecutive series of 22 patients and a critical analysis of the diagnostic criteria. J Headache Pain. 2013 Mar 20. 14(1):26. [Medline]. [Full Text].

  6. Porporatti AL, Costa YM, Bonjardim LR, Stuginski-Barbosa J, Conti PC, Martori AH. The coexistence of paroxysmal hemicrania and temporomandibular disorder: importance of multidisciplinary approach. Indian J Dent Res. 2014 Jan-Feb. 25(1):119-21. [Medline].

  7. Russell D, Vincent M. Chronic paroxysmal hemicrania. The Headaches. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2000. 741-9.

  8. Goadsby PJ, Lipton RB. A review of paroxysmal hemicranias, SUNCT syndrome and other short-lasting headaches with autonomic feature, including new cases. Brain. 1997 Jan. 120 ( Pt 1):193-209. [Medline].

  9. Matharu M, May A. Functional and structural neuroimaging in trigeminal autonomic cephalalgias. Curr Pain Headache Rep. 2008 Apr. 12(2):132-7. [Medline].

  10. Leone M, Bussone G. Pathophysiology of trigeminal autonomic cephalalgias. Lancet Neurol. 2009 Aug. 8(8):755-64. [Medline].

  11. Sjaastad O, Apfelbaum R, Caskey W, Christoffersen B, Diamond S, Graham J, et al. Chronic paroxysmal hemicrania (CPH). The clinical manifestations. A review. Ups J Med Sci Suppl. 1980. 31:27-33. [Medline].

  12. Kudrow DB, Kudrow L. Successful aspirin prophylaxis in a child with chronic paroxysmal hemicrania. Headache. 1989 May. 29(5):280-1. [Medline].

  13. Gladstein J, Holden EW, Peralta L. Chronic paroxysmal hemicrania in a child. Headache. 1994 Oct. 34(9):519-20. [Medline].

  14. Broeske D, Lenn NJ, Cantos E. Chronic paroxysmal hemicrania in a young child: possible relation to ipsilateral occipital infarction. J Child Neurol. 1993 Jul. 8(3):235-6. [Medline].

  15. Tarantino S, Vollono C, Capuano A, Vigevano F, Valeriani M. Chronic paroxysmal hemicrania in paediatric age: report of two cases. J Headache Pain. 2011 Apr. 12(2):263-7. [Medline]. [Full Text].

  16. Müller KI, Bekkelund SI. Hemicrania continua changed to chronic paroxysmal hemicrania after treatment with cyclooxygenase-2 inhibitor. Headache. 2011 Feb. 51(2):300-5. [Medline].

  17. Sjaastad O, Vincent M. Indomethacin responsive headache syndromes: chronic paroxysmal hemicrania and Hemicrania continua. How they were discovered and what we have learned since. Funct Neurol. 2010 Jan-Mar. 25(1):49-55. [Medline].

  18. Seidel S, Lieba-Samal D, Vigl M, Wöber C. Clinical features of unilateral headaches beyond migraine and cluster headache and their response to indomethacin. Wien Klin Wochenschr. 2011 Sep. 123(17-18):536-41. [Medline].

  19. Evers S, Bauer B, Suhr B, Voss H, Frese A, Husstedt IW. Cognitive processing is involved in cluster headache but not in chronic paroxysmal hemicrania. Neurology. 1999 Jul 22. 53(2):357-63. [Medline].

  20. Shabbir N, McAbee G. Adolescent chronic paroxysmal hemicrania responsive to verapamil monotherapy. Headache. 1994 Apr. 34(4):209-10. [Medline].

  21. Dahlöf C. Subcutaneous sumatriptan does not abort attacks of chronic paroxysmal hemicrania (CPH). Headache. 1993 Apr. 33(4):201-2. [Medline].

  22. Hannerz J, Jogestrand T. Intracranial hypertension and sumatriptan efficacy in a case of chronic paroxysmal hemicrania which became bilateral. (The mechanism of indomethacin in CPH). Headache. 1993 Jun. 33(6):320-3. [Medline].

  23. Pascual J, Quijano J. A case of chronic paroxysmal hemicrania responding to subcutaneous sumatriptan. J Neurol Neurosurg Psychiatry. 1998 Sep. 65(3):407. [Medline]. [Full Text].

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