Interictal pain in primary headache syndromes

A Combination of Indomethacin Farnesyl and Amitriptyline Is Effective for Continuous Interictal Pain with Probable Chronic Paroxysmal Hemicrania

A 26-year-old woman with a history of migraine reported right-sided, severe stabbing orbital pain with cranial autonomic symptoms (CASs) for approximately 2 years. The attack duration was approximately 30 minutes, with a frequency of twice per day. Taking loxoprofen was ineffective. Six months earlier, moderate pressing continuous interictal pain without CASs had developed. Indomethacin farnesyl completely resolved the attacks but had no effect on the interictal pain. The patient was diagnosed with probable chronic paroxysmal hemicrania in accordance with the International Classification of Headache Disorders (ICHD-3) (third version). Continuous interictal pain gradually disappeared with a combination of indomethacin farnesyl and amitriptyline.

A long-term prospective observational study in 31 patients with hemicrania continua

Introduction:

Till date, there is no prospective study in patients with hemicrania continua (HC).

Methods:

Patients fulfilling the international classification of headache disorders criteria for HC were evaluated prospectively. All patients were subjected to a detailed clinical interview, based on a structured questionnaire. Before starting indomethacin, all patients were instructed to fill a headache diary for at least 5 days. Gradual tapering of indomethacin was done at regular intervals.

Results:

We enrolled 41 patients over 4.5 years, 31 of whom met the criteria after confirming the indomethacin response. The mean age was 41 years, and 55% were female. The mean duration of headache was 43.6 months. All patients had continuous strictly unilateral pain with episodic exacerbations. At least one cranial autonomic feature was noted in 81% of patients. Twenty-five patients (81%) felt a sense of restlessness during exacerbations. The mean follow-up was 2.5 years. Three-fourths of patients noted a reduction in indomethacin dose after an average 2.5 of years follow-up. The mean reduction of the dose in the follow-up was statistically significant (172 mg vs. 110 mg, p < 0.001). All patients missed the drug for various reasons over the observation period. The headache reappeared within 48 h in 97% of patients.

Conclusion:

Misdiagnosis of HC is still very common. Patients may not volunteer about the background pain and will focus only on the exacerbations. HC rarely remits, but indomethacin requirements may decrease over time. Skipping of the effective drug leads to the immediate reappearance of pain.

Hemicrania Continua

Hemicrania continua (HC) is an indomethacin responsive primary chronic headache disorder which is currently classified as a subtype of trigeminal autonomic cephalalgias (TACs). It is not very uncommon. There are >1000 cases of HC in the literature, and it constitutes 1.7% of total headache in the clinic settings. Misdiagnosis for HC is very common at all clinical settings. A diagnosis of HC is missed even by neurologists and headache specialists. It is characterized by a continuous strictly unilateral headache with superimposed exacerbations. Just like other TACs, exacerbations are associated with cranial autonomic symptoms and restlessness. A large number of patients may have migrainous features (nausea, vomiting, photophobia, and phonophobia) during exacerbations phase. The “key” feature of HC is persistent featureless background headaches. However, patients and physicians may focus only on the exacerbation part. As durations, frequency and associated symptoms of exacerbations are highly variables; it may mimic a large number of primary and secondary headache disorders. Migraine and cluster headache are two most common misdiagnosed conditions. Another specific feature of HC is remarkable repose to indomethacin. A “complete” response to indomethacin is as “sine qua non” for HC. However, a few other medications may also be effective in a subset of HC patients. Various surgical procedures have been tried with mixed results in patients who were intolerant to indomethacin or other drugs.

Hemicrania continua: clinical review, diagnosis and management

Hemicrania continua (HC) is an indomethacin-responsive primary headache disorder which is currently classified under the heading of trigeminal autonomic cephalalgias (TACs). It is a highly misdiagnosed and underreported primary headache. The pooled mean delay of diagnosis of HC is 8.0 ± 7.2 years. It is not rare. We noted more than 1000 cases in the literature. It represents 1.7% of total headache patients attending headache or neurology clinic. Just like other TACs, it is characterized by strictly unilateral pain in the trigeminal distribution, cranial autonomic features in the same area and agitation during exacerbations/attacks. It is different from other TACs in one aspect. While all other TACs are episodic, HC patients have continuous headaches with superimposed severe exacerbations. The central feature of HC is continuous background headache. However, the patients may be worried only for superimposed exacerbations. Focusing only on exacerbations and ignoring continuous background headache are the most important factors for the misdiagnosis of HC. A large number of patients may have migrainous features during exacerbation phase. Up to 70% patients may fulfill the diagnostic criteria for migraine during exacerbations. Besides migraine, its exacerbations can mimic a large number of other primary and secondary headaches. The other specific feature of HC is a remarkable response to indomethacin. However, a large number of patients develop side effects because of the long-term use of indomethacin. A few other medications may also be effective in a subset of patients with HC. Various surgical interventions have been suggested for patients who are intolerant to indomethacin. Several aspects of HC are still not defined. There is a great heterogeneity in types of patients or articles on the HC in the literature. Diagnostic criteria have been modified several times over the years. The current diagnostic criteria are too restrictive in some aspects. We suggest a more accommodating type of criteria for the appendix of International Classification of Headache Disorder (ICHD).

Changes Over Time of Prescription and Nonprescription Analgesics for Headache With or Without Other Somatic Pain: Effects of Prescription Regulatory Changes

The aim of this study was to examine the association and changes over time between headaches with or without somatic pain and the self-reported use of pain medication. The study further examined whether the law amendment in 2003 in Norway releasing the sale of nonprescription drugs to shops has changed these relationships. The study is on the basis of repeated self-report cross-sectional studies from 1998 to 2012 in Norway. A total of 27,247 adults were included. As expected, there was a strong association between headache, especially headache with comorbid somatic pain and consumption of prescription versus nonprescription analgesics, although the overall consumption decreased slightly after 2003. We conclude that the strong association between especially headache, whether complicated by somatic pain or not, and the consumption of prescription-free analgesics did not seem to be negatively affected by the prescription regulatory changes. The very high use of nonprescription medication among headache patients suggests the need for continued observation and information regarding the risk of medication-overuse headache.

PERSPECTIVE

In Norway, headache was strongly associated with use of over-the-counter analgesics, for other somatic pain prescription analgesics were equally common. Between 1998 and 2012 headache and related analgesic consumption was reduced and other somatic pain increased. Making over-the-counter analgesics available outside pharmacies in 2003 did not increase the self-reported intake.

Linear interictal pain in Epicrania Fugax

Epicrania Fugax is a paroxysmal, short-lasting, head pain moving across one hemicranium, describing a linear or zag trajectory, starting and ending in territories of different nerves. Between attacks, patients are usually free of symptoms. We describe an Epicrania Fugax patient complaining of interictal pain. The interictal pain was line-shaped and extended across the usual starting and ending points of the typical Epicrania Fugax paroxysms. Although rarely encountered, persistent linear pain may be a feature of Epicrania Fugax.

Linear interictal pain in epicrania fugax: a reply

This is a reply to the comments on our article "Linear headache: a recurrent unilateral head pain circumscribed in a line-shaped area" published in JHP 2014 Jun 26; 15:45. In the comments, the authors raise a question whether the linear headache (LH) we reported be a linear interictal pain in epicranial fugax (EF), based on a case they reported. We think that the LH is not a linear interictal pain in EF based on our observations and considerations.

Hypnic headache: a review of 2012 publications

Hypnic headache is a rare primary headache disorder affecting middle age and above with a dull pain exclusively at nighttime. This article aims to review and discuss the most recent articles published in the year 2012 regarding hypnic headache. We will also discuss specific cases of pharmacological and nonpharmacologic successes in treating this rare disorder.

Paroxysmal hemicrania: a retrospective study of a consecutive series of 22 patients and a critical analysis of the diagnostic criteria

Background

Paroxysmal hemicrania (PH) is a probably underreported primary headache disorder. It is characterized by repeated attacks of severe, strictly unilateral pain lasting 2 to 30 minutes localized to orbital, supraorbital, and temporal areas accompanied by ipsilateral autonomic features. The hallmark of PH is the absolute cessation of the headache with indomethacin. However, these all features may not be present in all cases and a few cases may remain unclassified according to the 2nd Edition of The International classification of Headache Disorders (ICHD-II) criteria for PH.

Methods

Twenty-two patients were included in this retrospective observation.

Results

We describe 17 patients, observed over six years, who fulfilled the ICHD-II criteria for PH. In parallel, we identified five more patients in whom one of the features of the diagnostic criteria for PH was missing. Two patients did not show any evidence of cranial autonomic feature during the attacks of headache. Another two patients did not fulfill the criteria for PH as the maximum attack frequency was less than five. One patient had an incomplete response to indomethacin.

Conclusion

A subset of patients may not have all the defined features of PH and there is a need for refinement of the existing diagnostic criteria.