Hemicrania Continua Responsive to Intravenous Methyl Prednisolone

Steroids in Headache: A Comprehensive Review of Recent Research

Background

Headache is an extremely common symptom of the general outpatient department and also the headache clinic, with prevalence of 48.9% in the general population. None has ever experienced headache in life time. Headache is seen in 1 patient out of 10 general practitioner (GP) consultations, 1 referral out of 3 is headache in neurology OPD, and 1 in 5 of all emergency medical admissions. Of all headaches, around 98% constitute primary headache: migraine without aura, tension headache, and cluster headache. With advancement in various drug modalities, certain headache forms respond less well to the regular approved medications, and some headaches are complicated by the analgesic itself. Steroids have been tried in many subtypes of headache, especially in primary forms of headache with dysautonomia, headache with trigeminal pathway activation and disinhibition, and in certain medication-culprit headaches. This subgroup of headaches is almost a challenge in an emergency for the headache expert as well. So, we need to assess the role of steroids in less well-responsive headaches.

Summary

Current reviewed evidence on the role of steroids in primary headache suggests that steroids have a role in status migrainosus and medication overuse headache when used in the mentioned and monitored manner. Consideration and further exploration of its role in other primary headaches may reveal insight into steroid efficacy as a treatment modality in various subtypes of headache.

Key message

Steroids, when used cautiously in specifically selected primary headaches under supervision, proved miraculous where other modalities failed.

Therapeutical approaches to paroxysmal hemicrania, hemicrania continua and short lasting unilateral neuralgiform headache attacks: a critical appraisal

Background

Hemicrania continua (HC), paroxysmal hemicrania (PH) and short lasting neuralgiform headache attacks (SUNCT and SUNA) are rare syndromes with a difficult therapeutic approach. The aim of this review is to summarize all articles dealing with treatments for HC, PH, SUNCT and SUNA, comparing them in terms of effectiveness and safety.

Methods

A survey was performed using the pubmed database for documents published from the 1st January 1989 onwards. All types of articles were considered, those ones dealing with symptomatic cases and non-English written ones were excluded.

Results

Indomethacin is the best treatment both for HC and PH. For the acute treatment of HC, piroxicam and celecoxib have shown good results, whilst for the prolonged treatment celecoxib, topiramate and gabapentin are good options besides indomethacin. For PH the best drug besides indomethacin is piroxicam, both for acute and prolonged treatment. For SUNCT and SUNA the most effective treatments are intravenous or subcutaneous lidocaine for the acute treatment of active phases and lamotrigine for the their prevention. Other effective therapeutic options are intravenous steroids for acute treatment and topiramate for prolonged treatment. Non-pharmacological techniques have shown good results in SUNCT and SUNA but, since they have been tried on a small number of patients, the reliability of their efficacy is poor and their safety profile mostly unknown.

Conclusions

Besides a great number of treatments tried, HC, PH, SUNCT and SUNA management remains difficult, according with their unknown pathogenesis and their rarity, which strongly limits the studies upon these conditions. Further studies are needed to better define the treatment of choice for these conditions.

Electronic supplementary material

The online version of this article (doi:10.1186/s10194-017-0777-3) contains supplementary material, which is available to authorized users.

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).

Treatment of miscellaneous idiopathic headache disorders (Group 4 of the IHS classification)--report of an EFNS task force

BACKGROUND AND PURPOSE

Certain miscellaneous idiopathic headache disorders, which are regarded as entities, are grouped in Chapter 4 of the International Classification of Headache Disorders. Recent epidemiological research suggests that these headache disorders are underdiagnosed.

OBJECTIVES

To give expert recommendations for the different drug and non-drug treatment procedures of these different headache disorders based on a literature search and on consensus of an expert panel.

METHODS

All available medical reference systems were screened for all kinds of clinical studies on these headache disorders. The findings in these studies were evaluated according to the recommendations of the EFNS resulting in level A, B or C recommendations and good practice points.

RECOMMENDATIONS

For all headache disorders, acute and prophylactic drug treatment is recommended based on case series and on expert consensus. Furthermore, recommendations for the differential diagnoses are given because these headache disorders can also present with a symptomatic form. The most effective drug for the majority of these headache disorders is indomethacin, mostly applied as long-term or short-term prophylaxis.

Post-infectious new daily persistent headache may respond to intravenous methylprednisolone

New daily persistent headache (NDPH) is a subtype of chronic daily headache (CDH) that starts acutely and continues as a daily headache from the onset. It is considered as one of the most treatment refractory of all headache syndromes. The pathophysiology is largely unknown. Viral infections, extracranial surgery, and stressful life events are considered as triggers for the onset of NDPH. A few patients may have the onset of their symptoms during an infection. Here we report nine patients with NDPH like headache. All of them had a history suggestive of extracranial infections a few weeks prior to the onset of headache. All patients received intravenous methyl prednisolone (IV MPS) for 5 days. Intravenous MPS was followed by Oral steroids for 2–3 weeks in six patients. The relief of headache started between the second and fifth days of infusion in all patients. The steady improvement in headache continued and seven patients experienced almost complete improvement within 2 weeks. Two other patients showed complete improvement between 6 and 8 weeks after initiation of IV MPS therapy. We conclude that NDPH-like headache may occur as a post infectious process following a recent infection. We also speculate on the possible mechanisms of headache in our patients.

Hemicrania continua unresponsive or partially responsive to indomethacin: does it exist? A diagnostic and therapeutic dilemma

Hemicrania continua (HC) is a primary headache disorder characterized by a continuous, unilateral headache that varies in intensity, waxing and waning without disappearing completely. Ipsilateral cranial autonomic features and response to indomethacin are essential features for the diagnosis of HC. We hereby, describe three patients with the clinical phenotypes of HC in whom response to indomethacin was either incomplete or not sustained. We also review the literature especially for the presence of indomethacin response and ipsilateral cranial autonomic features.