Chronic Paroxysmal Hemicrania Treatment & Management

  • Author: Manish K Singh, MD; more...
 
Updated: Jan 30, 2012
 

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.[14]

Uncertain or ineffective treatments

The efficacy of sumatriptan in CPH is still controversial.[15, 16, 17] 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.

Proceed to Medication
 
 
Contributor Information and Disclosures
Author

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 Association of Physicians of Indian Origin, American Headache Society, American Medical Association, and American Society of Regional Anesthesia and Pain Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Jashvant Patel, MD  Medical Director, Department of Pain Medicine and Comprehensive Rehabilitation, Medical College of Pennsylvania Hahnemann University

Jashvant Patel, 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, and Medical Society of the State of New York

Disclosure: Nothing to disclose.

Additional Contributors

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

References

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

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

  3. Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Headache Classification Committee of the International Headache Society. Cephalalgia. 1988;8 Suppl 7:1-96. [Medline].

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

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

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

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  8. 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].

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

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

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

  12. 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. Sep 2011;123(17-18):536-41. [Medline].

  13. 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. Jul 22 1999;53(2):357-63. [Medline].

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

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

  16. 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. Jun 1993;33(6):320-3. [Medline].

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

 
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