Hemicrania Continua occurs in men and women at all ages. These patients have moderate unilateral dull pain, with icepick pains intermittently during the day, and three-fifths of the patients have focal, intense pain lasting minutes. The pain may be increased with alcohol or physical exertion. Typical migrainous features may be present, such as sensitivity to light and accompanying nausea. There are many patients who do not fulfill all of these criteria, but who have unilateral dull or throbbing pain on a daily basis, with migraine features. They usually also experience intermittent icepick-type jabbing pains. Autonomic features may accompany flare-ups.
Indomethacin, as outlined in the above section on CPH, is the drug of choice with hemicrania continua. Patients who fit some but not all of the criteria for hemicrania continua also may respond to indomethacin. If indomethacin is not able to be used, or is not helpful, then proceeding along migraine prevention lines is required. Amitriptyline, naproxen, and calcium blockers may be helpful. (See Table 13.3.) Triptans may be useful in occasional patients.
Clinical Characteristics of Hemicrania Continua
- Unilateral severe pain lasting 5-60 minutes, usually pulsation or throbbing, occurs in 60% of patients.
- Nausea or photophobia may be present with the severe pain.
- Attacks occur 3-5 times per 24 hours (in 60% of patients)
- Underlying unilateral aching, dull pain in all patients.
- Patients may be awakened from sleep with the severe pain.
- Icepick stabbing pain throughout the day.
- Physical exertion increases the pain in some patients.
- Alcohol may increase the pain.
- Indomethacin is effective in 4/5 patients.
- Ergots, NSAIDs, tricyclics, or verapamil are effective for some patients.
- The painful flare-ups may be associated with autonomic; features, such as conjunctival injection, eye tearing, nasal stiffness, etc.