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Paroxysmal hemicrania: Treatment and prognosis

Manjit S Matharu, MD
Anna S Cohen, MD
Section Editor
Jerry W Swanson, MD, MHPE
Deputy Editor
John F Dashe, MD, PhD


The trigeminal autonomic cephalalgias (TACs) are a group of primary headache disorders characterized by unilateral trigeminal distribution pain that occurs in association with ipsilateral cranial autonomic features [1,2]. The TACs include cluster headache, paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks, and hemicrania continua [3].

Despite their common elements, the TACs differ in attack duration and frequency, as well as the response to therapy (table 1).

Hemicrania continua is characterized by continuous pain with exacerbations

Cluster headache has a relatively long attack duration and relatively low attack frequency

Paroxysmal hemicrania has intermediate attack duration and frequency


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Literature review current through: Sep 2016. | This topic last updated: Jan 8, 2014.
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  1. Goadsby PJ, Lipton RB. A review of paroxysmal hemicranias, SUNCT syndrome and other short-lasting headaches with autonomic feature, including new cases. Brain 1997; 120 ( Pt 1):193.
  2. Goadsby PJ. Trigeminal autonomic cephalalgias. Pathophysiology and classification. Rev Neurol (Paris) 2005; 161:692.
  3. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013; 33:629.
  4. Boes CJ, Dodick DW. Refining the clinical spectrum of chronic paroxysmal hemicrania: a review of 74 patients. Headache 2002; 42:699.
  5. Sjaastad O, Apfelbaum R, Caskey W, et al. Chronic paroxysmal hemicrania (CPH). The clinical manifestations. A review. Ups J Med Sci Suppl 1980; 31:27.
  6. Matharu MS, Cohen AS, Frackowiak RS, Goadsby PJ. Posterior hypothalamic activation in paroxysmal hemicrania. Ann Neurol 2006; 59:535.
  7. Cittadini E, Matharu MS, Goadsby PJ. Paroxysmal hemicrania: a prospective clinical study of 31 cases. Brain 2008; 131:1142.
  8. Fuad F, Jones NS. Paroxysmal hemicrania and cluster headache: two discrete entities or is there an overlap? Clin Otolaryngol Allied Sci 2002; 27:472.
  9. Lambru G, Matharu M. Management of trigeminal autonomic cephalalgias in children and adolescents. Curr Pain Headache Rep 2013; 17:323.
  10. Sjaastad, O. Chronic paroxysmal hemicrania. In: Handbook of Clinical Neurology, Vol.48, Vinken, PJ, Bruyn, GW, Klawans, HL, Rose, FC (Eds). Elsevier Science, Amsterdam 1986. p.257.
  11. Sjaastad O, Stovner LJ, Stolt-Nielsen A, et al. CPH and hemicrania continua: requirements of high indomethacin dosages--an ominous sign? Headache 1995; 35:363.
  12. Pareja JA, Caminero AB, Franco E, et al. Dose, efficacy and tolerability of long-term indomethacin treatment of chronic paroxysmal hemicrania and hemicrania continua. Cephalalgia 2001; 21:906.
  13. Matharu MS, Goadsby PJ. Functional brain imaging in hemicrania continua: implications for nosology and pathophysiology. Curr Pain Headache Rep 2005; 9:281.
  14. Dodick D. Hemicrania continua: diagnostic criteria and nosologic status. Cephalalgia 2001; 21:869.
  15. Frölich JC. A classification of NSAIDs according to the relative inhibition of cyclooxygenase isoenzymes. Trends Pharmacol Sci 1997; 18:30.
  16. Markowitz S, Saito K, Moskowitz MA. Neurogenically mediated leakage of plasma protein occurs from blood vessels in dura mater but not brain. J Neurosci 1987; 7:4129.
  17. Buzzi MG, Sakas DE, Moskowitz MA. Indomethacin and acetylsalicylic acid block neurogenic plasma protein extravasation in rat dura mater. Eur J Pharmacol 1989; 165:251.
  18. Williamson DJ, Hargreaves RJ. Neurogenic inflammation in the context of migraine. Microsc Res Tech 2001; 53:167.
  19. Cutrer, FM, Limmroth, V, Waeber, C, et al. New targets for antimigraine drug development. In: Headache, Goadsby PJ, Silberstein SD (Eds), Butterworth-Heinemann, Philadelphia 1997. p.59.
  20. Moskowitz MA, Cutrer FM. SUMATRIPTAN: a receptor-targeted treatment for migraine. Annu Rev Med 1993; 44:145.
  21. Du ZY, Li XY. Inhibitory effects of indomethacin on interleukin-1 and nitric oxide production in rat microglia in vitro. Int J Immunopharmacol 1999; 21:219.
  22. Thomsen LL, Olesen J. Nitric oxide in primary headaches. Curr Opin Neurol 2001; 14:315.
  23. Summ O, Andreou AP, Akerman S, Goadsby PJ. A potential nitrergic mechanism of action for indomethacin, but not of other COX inhibitors: relevance to indomethacin-sensitive headaches. J Headache Pain 2010; 11:477.
  24. Goadsby PJ, Uddman R, Edvinsson L. Cerebral vasodilatation in the cat involves nitric oxide from parasympathetic nerves. Brain Res 1996; 707:110.
  25. Uddman R, Goadsby PJ, Jansen-Olesen I, Edvinsson L. Helospectin-like peptides: immunochemical localization and effects on isolated cerebral arteries and on local cerebral blood flow in the cat. J Cereb Blood Flow Metab 1999; 19:61.
  26. Goadsby PJ, Edvinsson L. Neuropeptide changes in a case of chronic paroxysmal hemicrania--evidence for trigemino-parasympathetic activation. Cephalalgia 1996; 16:448.
  27. Slavik RS, Rhoney DH. Indomethacin: a review of its cerebral blood flow effects and potential use for controlling intracranial pressure in traumatic brain injury patients. Neurol Res 1999; 21:491.
  28. Jensen K, Freundlich M, Bünemann L, et al. The effect of indomethacin upon cerebral blood flow in healthy volunteers. The influence of moderate hypoxia and hypercapnia. Acta Neurochir (Wien) 1993; 124:114.
  29. Biestro AA, Alberti RA, Soca AE, et al. Use of indomethacin in brain-injured patients with cerebral perfusion pressure impairment: preliminary report. J Neurosurg 1995; 83:627.
  30. Jensen K, Ohrström J, Cold GE, Astrup J. The effects of indomethacin on intracranial pressure, cerebral blood flow and cerebral metabolism in patients with severe head injury and intracranial hypertension. Acta Neurochir (Wien) 1991; 108:116.
  31. Antonaci F, Sjaastad O. Chronic paroxysmal hemicrania (CPH): a review of the clinical manifestations. Headache 1989; 29:648.
  32. Kudrow DB, Kudrow L. Successful aspirin prophylaxis in a child with chronic paroxysmal hemicrania. Headache 1989; 29:280.
  33. Evers S, Husstedt IW. Alternatives in drug treatment of chronic paroxysmal hemicrania. Headache 1996; 36:429.
  34. Mateo I, Pascual J. Coexistence of chronic paroxysmal hemicrania and benign cough headache. Headache 1999; 39:437.
  35. Hannerz J, Ericson K, Bergstrand G. Chronic paroxysmal hemicrania: orbital phlebography and steroid treatment. A case report. Cephalalgia 1987; 7:189.
  36. Durko, A, Klimek, A. Naproxen in the treatment of chronic paroxysmal hemicrania. Cephalalgia 1987; 7:361.
  37. Pradalier A, Dry J. [Chronic paroxysmal hemicrania. Treatment with indomethacin and diclofenac]. Therapie 1984; 39:185.
  38. Sjaastad O, Antonaci F. A piroxicam derivative partly effective in chronic paroxysmal hemicrania and hemicrania continua. Headache 1995; 35:549.
  39. Siow HC. Seasonal episodic paroxysmal hemicrania responding to cyclooxygenase-2 inhibitors. Cephalalgia 2004; 24:414.
  40. Chakravarty A, Mukherjee A, Roy D. Trigeminal autonomic cephalgias and variants: clinical profile in Indian patients. Cephalalgia 2004; 24:859.
  41. Lisotto C, Maggioni F, Mainardi F, Zanchin G. Rofecoxib for the treatment of chronic paroxysmal hemicrania. Cephalalgia 2003; 23:318.
  42. Mathew NT, Kailasam J, Fischer A. Responsiveness to celecoxib in chronic paroxysmal hemicrania. Neurology 2000; 55:316.
  43. Zidverc-Trajkovic J, Pavlovic AM, Mijajlovic M, et al. Cluster headache and paroxysmal hemicrania: differential diagnosis. Cephalalgia 2005; 25:244.
  44. de Almeida DB, Cunali PA, Santos HL, et al. Chronic paroxysmal hemicrania in early childhood: case report. Cephalalgia 2004; 24:608.
  45. Schlake HP, Böttger IG, Grotemeyer KH, et al. Single photon emission computed tomography (SPECT) with 99mTc-HMPAO (hexamethyl propylenamino oxime) in chronic paroxysmal hemicrania--a case report. Cephalalgia 1990; 10:311.
  46. Shabbir N, McAbee G. Adolescent chronic paroxysmal hemicrania responsive to verapamil monotherapy. Headache 1994; 34:209.
  47. May A, Leone M, Afra J, et al. EFNS guidelines on the treatment of cluster headache and other trigeminal-autonomic cephalalgias. Eur J Neurol 2006; 13:1066.
  48. Coria F, Claveria LE, Jimenez-Jimenez FJ, de Seijas EV. Episodic paroxysmal hemicrania responsive to calcium channel blockers. J Neurol Neurosurg Psychiatry 1992; 55:166.
  49. Warner JS, Wamil AW, McLean MJ. Acetazolamide for the treatment of chronic paroxysmal hemicrania. Headache 1994; 34:597.
  50. Pascual J, Quijano J. A case of chronic paroxysmal hemicrania responding to subcutaneous sumatriptan. J Neurol Neurosurg Psychiatry 1998; 65:407.
  51. 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; 33:320.
  52. Antonaci F, Pareja JA, Caminero AB, Sjaastad O. Chronic paroxysmal hemicrania and hemicrania continua: anaesthetic blockades of pericranial nerves. Funct Neurol 1997; 12:11.
  53. Rossi P, Di Lorenzo G, Faroni J, Sauli E. Seasonal, extratrigeminal, episodic paroxysmal hemicrania successfully treated with single suboccipital steroid injections. Eur J Neurol 2005; 12:903.
  54. Albertyn J, Barry R, Odendaal CL. Cluster headache and the sympathetic nerve. Headache 2004; 44:183.