Chronic Paroxysmal Hemicrania Treatment & Management

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

Approach Considerations

The treatment of choice for chronic paroxysmal hemicrania (CPH) is indomethacin, which has an absolute effect on the symptoms. Episodic cluster headache (CH) and CPH respond well to this agent. Take precautions to prevent serious gastrointestinal and renal complications secondary to long-term use of indomethacin.

Other medications that may provide relief include the following:

  • Salicylates (aspirin)
  • Naproxen
  • Prednisone
  • Celecoxib
  • Piroxicam
  • Acetazolamide
  • Ergotamine

The results of one prospective, open trial conducted with 10 patients experiencing CPH suggested that acetylsalicylic acid (and probably naproxen and diclofenac) and verapamil (for prophylaxis) are the most effective second-line drugs.

In another report, 2 teenaged girls who demonstrated dramatic, yet incomplete, improvement with indomethacin had nearly complete relief with verapamil monotherapy. [20]

Uncertain or ineffective treatments

The efficacy of sumatriptan in CPH is still controversial. [21, 22, 23] Oxygen, lithium, carbamazepine, and other anticonvulsants are ineffective in patients with CPH.

Anesthetic blockade of the occipital nerves and supraorbital nerve has not provided significant relief. Occipital nerve blockade helps in distinguishing CPH and HC from cervicogenic headache. Supraorbital nerve blockade may help in distinguishing hemicrania continua (HC) and supraorbital nerve neuralgia (in which nerve block is markedly effective).

Reliable evidence for the efficacy of chiropractic manipulation, acupuncture, or surgical management in the treatment of CPH does not exist.

Consultations

Consult with an ophthalmologist to evaluate ocular pathology such as glaucoma or orbital pseudotumor.