Paroxysmal Hemicrania

Aka: Paroxysmal Hemicrania

1. See Also
   1. Cluster Headache
   2. Hemicrania Continua
   3. Short-Lasting Unilateral Neuralgiform Headache Attacks with Conjunctival Injection or Tearing (SUNCT Headache)
   4. Headache
   5. Headache Red Flag
   6. Organic Headache
   7. Chronic Daily Headache
2. Classification
   1. Short duration
   2. Trigeminal Autonomic Cephalgia
      1. Headaches similar to Cluster Headache
      2. Unilateral trigeminal distribution symptoms with autonomic features
3. Symptoms
   1. Severity
      1. Severe pain
   2. Characteristics
      1. Unilateral orbital, supraorbital or temporal Headache
   3. Timing
      1. Duration of 2-30 minutes
      2. Recurs more than 5 times daily on >50% of days
   4. Palliative
      1. Relieved with Indomethacin (unlike Cluster Headaches which are not relieved with Indomethacin)
   5. Associated Symptoms (at least one of the following autonomic symptoms characteristic of Cluster Headaches)
      1. Lacrimation
      2. Ipsilateral forehead or facial Flushing or sweating
      3. Ipsilateral Nasal Discharge
      4. Affected eye red with dilated Conjunctival vessels (Conjunctival injection)
      5. Restlessness, pacing or rocking head in hands
      6. Horner's Syndrome (30% of cases)
         1. Ipsilateral Ptosis
         2. Ipsilateral pupillary constriction (Miosis)
4. Diagnosis
   1. Characteristics: At least 20 or more Headaches meeting the following criteria
      1. Severe to very severe unilateral orbital, supraorbital or temporal pain lasting 2-30 minutes
      2. Headaches >5 times daily
      3. Prevented by therapeutic Indomethacin doses 150 to 225 mg in divided dosing per day
      4. Headache with at least one of the following ipsilateral autonomic symptoms
         1. Conjunctival injection or Lacrimation
         2. Nasal congestion or Rhinorrhea
         3. Eyelid Edema
         4. Forehead and facial sweating
         5. Miosis or Ptosis
         6. Restlessness or Agitation
   2. Timing
      1. Episodic
         1. Two or more cluster periods lasting 7-365 days and separated by pain-free remissions >3 month
      2. Chronic
         1. Episodes recur for more than 1 year without remission or with remission <3 month
   3. References
      1. (2018) Cephalgia 38(1):1-211 [PubMed]
5. Differential Diagnosis
   1. See Cluster Headache
6. Management
   1. Indomethacin
7. References
   1. (2004) Cephalgia 24(suppl 1): 9-160 [PubMed]
   2. Yancey (2014) Am Fam Physician 89(8): 642-8 [PubMed]