Treatment
- Since this is a continuous daily headache, the goal of treatment is focused on preventive therapy: What to take on a daily basis to try to lessen the frequency and/or severity of the headaches. Preventive medicines generally take 4-6 weeks to start working and 2-3 months for full effect, assuming the correct dose of the medication is reached. An exception to this rule is Indomethacin, which can work very quickly. These are the medications used most commonly, although this is not an all- inclusive list.
- Nonsteroidal anti-inflammatory drugs (NSAIDs):
---Indomethacin (Indocin). This is the gold standard treatment of hemicrania continua, and this headache type is diagnosed by its complete resolution on Indomethacin. If hemicrania continua is suspected, a 15 day “Indomethacin trial” is started, assuming the medicine is safe with your other medical history/issues, and other medications being used. Your doctor would be able to tell you whether this would be a safe medicine or not for you. During the “Indomethacin trial”, a daily acid reflux/heart burn/GERD medication such as omeprazole or similar medication is often added to lessen potential stomach irritation/side effects. If your doctor determines Indomethacin to be safe for you, 25 mg three times daily with food (morning, afternoon, evening) is started for 5 days. If the headache persists in 5 days, the dose is increased to 50 mg three times daily with food for 5 days. If the headache persists in 5 days, the dose is increased to 75 mg three times daily for a final 5 days. Each of these 5 day increments in dose escalation results in a cumulative 15 day “Indomethacin trial”. If the headache persists after the full 15 days of increasing doses, it is very unlikely to be hemicrania continua and the Indomethacin is stopped. However, if the headache resolves completely at any time along the dose escalation, the patient remains at that dose for several weeks. This is then followed by an attempt to try to slowly wean back off completely, or to the lowest dose that effectively prevents headaches from breaking through.
---Other less effective NSAIDs such as Celecoxib (Celebrex), Naproxen (Aleve), Ibuprofen (Advil, Motrin), Diclofenac (Cataflam), and Aspirin may sometimes be helpful. - Anti-convulsant (Anti-seizure) medications:
---Topiramate (Topamax)
---Gabapentin (Neurontin)
---Divalproex sodium (Depakote)
---Zonisamide (Zonegran)
---Carbamazepine (Tegretol) - Anti-depressant/Anti-anxiety medications:
---Amitriptyline (Elavil)
---Nortriptyline (Pamelor)
---Venlafaxine XR (Effexor XR)
---Desvenlafaxine (Pristiq)
---Duloxetine (Cymbalta) - Anti-hypertensive (blood pressure) medications:
---Verapamil (Calan)
---Propranolol (Inderal)
---Metoprolol (Toprol)
---Atenolol (Tenormin)
---Nadolol (Corgard)
---Lisinopril (Zestril)
---Candesartan (Atacand) - Others:
---Occipital nerve block
---Short courses of steroids such as Prednisone can sometimes give some temporary relief. - Biologics:
---Botox
