Chronic Paroxysmal Hemicrania Treatment & Management

Updated: Jun 12, 2019
  • Author: Monica Saini, MD, MBBS, MRCP(UK); more...
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Approach Considerations

The treatment of choice for chronic paroxysmal hemicrania (CPH) is indomethacin, which has an absolute effect on the symptoms. Episodic cluster headache (CH) and CPH respond well to this agent. Take precautions to prevent serious gastrointestinal and renal complications secondary to long-term use of indomethacin. Indomethacin should be administered in three or more doses per day because of its short half-life time of 4 hours. [3]

Approximately 30% of patients report dose-limiting side effects with indomethacin and about 20% may discontinue indomethacin due to side effects. The evidence for other medications is available from only open studies. [23] The best evidence amongst these medications is for verapamil. Other medications with reported benefits include acetazolamide, topiramate, piroxicam, and aspirin. [24]

Emerging treatments

Non-invasive vagus nerve stimulation (nVNS) has been reported to be benificial in small cohorts of patients. [25, 26]

Occipital nerve stimulation was demonstrated to be effective in one patient, with a follow-up of more than 10 years. Patient reported a sustained efficacy of >50% reduction in attack frequency, with complete resolution at final follow-up such that indomethacin could be discontinued. [27]

Deep brain stimulation (DBS), targeting the posterior hypothalamus, has been used to treat patients with chronic, medically refractory TACs (CH, PH and SUNCT), achieving a response rate of around 60%. [28]

Uncertain or ineffective treatments

Subcutaneous sumatriptan is ineffective. [3]

Anaesthetic blockades of pericranial nerves are said to be ineffective.

Oxygen, lithium, carbamazepine, and other anticonvulsants are ineffective in patients with CPH.

Anesthetic blockade of the occipital nerves and supraorbital nerve has not provided significant relief. Occipital nerve blockade helps in distinguishing CPH and HC from cervicogenic headache. Supraorbital nerve blockade may help in distinguishing hemicrania continua (HC) and supraorbital nerve neuralgia (in which nerve block is markedly effective).

Reliable evidence for the efficacy of chiropractic manipulation, acupuncture, or surgical management in the treatment of CPH does not exist.


Consult with an ophthalmologist to evaluate ocular pathology such as glaucoma or orbital pseudotumor.