How are paroxysmal hemicrania headache treated
Once the diagnosis is established and neuroimaging is normal, how are these headaches treated?
The hallmark of PHs is the absolute cessation of the headache with indomethacin. Initial therapy consists of 25 mg indomethacin 3 times daily. If there is no response or if there is a partial response after 1 week, increase the dose to 50 mg 3 times a day, and on rare occasion up to 75 mg 3 times a day. Complete resolution of the headache is prompt, usually occurring within 1 or 2 days of initiating the effective dose. Occasionally, suppositories are better tolerated than oral indomethacin. Very rarely, some patients require indomethacin doses as high as 300 mg/day. Recent reports suggest that a need for high indomethacin doses may be an ominous sign pointing to an underlying specific medical or structural etiology. Advise patients of the risk of gastritis and ulcer disease, as well as the other side effects of indomethacin. In patients with CPH who are on indomethacin, consider concurrent treatment with misoprostol or histamine (H-2) receptor antagonists or a proton pump inhibitor.
