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Headache May 2021Indomethacin is a nonsteroidal anti-inflammatory drug whose mechanism of action in certain types of headache disorders remains unknown. The so-called... (Review)
Review
BACKGROUND
Indomethacin is a nonsteroidal anti-inflammatory drug whose mechanism of action in certain types of headache disorders remains unknown. The so-called indomethacin-responsive headache disorders consist of a group of conditions with a very different presentation that have a particularly good response to indomethacin. The response is so distinct as to be used in the definition of two: hemicrania continua and paroxysmal hemicrania.
METHODS
This is a narrative literature review. PubMed and the Cochrane databases were used for the literature search.
RESULTS
We review the main pharmacokinetic and pharmacodynamics properties of indomethacin useful for daily practice. The proposed mechanisms of action of indomethacin in the responsive headache disorders, including its effect on cerebral blood flow and intracranial pressure, with special attention to nitrergic mechanisms, are covered. The current evidence for its use in primary headache disorders, such as some trigeminal autonomic cephalalgias, cough, hypnic, exertional or sexual headache, and migraine will be covered, as well as its indication for secondary headaches, such as those of posttraumatic origin.
CONCLUSION
Increasing understanding of the mechanism(s) of action of indomethacin will enhance our understanding of the complex pathophysiology that might be shared by indomethacin-sensitive headache disorders.
Topics: Anti-Inflammatory Agents, Non-Steroidal; Headache; Humans; Indomethacin; Treatment Outcome
PubMed: 34105154
DOI: 10.1111/head.14111 -
Neurology India 2021Migraine is a common disabling primary headache condition. Although strives have been made in treatment, there remains an unmet need for safe, effective acute, and... (Review)
Review
BACKGROUND
Migraine is a common disabling primary headache condition. Although strives have been made in treatment, there remains an unmet need for safe, effective acute, and preventative treatments. The promising concept of neuromodulation of relevant neuronal targets in a noninvasive fashion for the treatment of primary headache disorders has led to the trial of numerous devices over the years.
OBJECTIVE
We aimed to review the evidence on current neuromodulation treatments available for the management of primary headache disorders.
METHODS
Randomized controlled trial as well as open-label and real-world studies on central and peripheral cephalic and noncephalic neuromodulation modalities in primary headaches were critically reviewed.
RESULTS
The current evidence suggests a role of single-pulse transcranial magnetic stimulation, supraorbital nerve stimulation, and remote noncephalic electrical stimulation as migraine abortive treatments, with stronger evidence in episodic rather than in chronic migraine. Single-pulse transcranial magnetic stimulation and supraorbital nerve stimulation also hold promising evidence in episodic migraine prevention and initial positive evidence in chronic migraine prevention. More evidence should clarify the therapeutic role of the external vagus nerve stimulation and transcranial direct current stimulation in migraine. However, external vagus nerve stimulation may be effective in the acute treatment of episodic but not chronic cluster headache, in the prevention of hemicrania continua and paroxysmal hemicrania but not of short-lasting neuralgiform headache attacks. The difficulty in setting up sham-controlled studies has thus far prevented the publication of robust trials. This limitation along with the cost of these therapies has meant that their use is limited in most countries.
CONCLUSION
Neuromodulation is a promising nonpharmacological treatment approach for primary headaches. More studies with appropriate blinding strategies and reduction of device cost may allow more widespread approval of these treatments and in turn increase clinician's experience in neuromodulation.
Topics: Cluster Headache; Headache; Humans; Migraine Disorders; Transcranial Direct Current Stimulation; Vagus Nerve Stimulation
PubMed: 34003164
DOI: 10.4103/0028-3886.315998 -
Neurology India 2021Paroxysmal Hemicrania (PH) is classified under trigeminal autonomic cephalalgia (TAC) as per the International Classification of Headache Disorders (ICHD). Since the... (Review)
Review
Paroxysmal Hemicrania (PH) is classified under trigeminal autonomic cephalalgia (TAC) as per the International Classification of Headache Disorders (ICHD). Since the first description by 0ttar Sjaastad and Inge Dale in 1974, PH has been reported by many authors. A greater understanding of PH phenotype and pathophysiology has resulted in the evolution of its diagnostic criteria, and management. We tabulated major case series of PH to describe the epidemiology, clinical features and recent updates of PH. PH is a rare headache characterized by daily, multiple paroxysms of unilateral, short-lasting (mean duration <20 minutes), side-locked headache in the distribution of ophthalmic division of trigeminal nerve with associated profound cranial autonomic symptoms. Recent ICHD classification added "restlessness" to the criteria for PH. Pain should completely respond to indomethacin to fulfil the diagnostic criteria of PH. PH should be differentiated from cluster headache, SUNCT/SUNA, and other short-lasting side-locked headaches. Trigeminal afferents possibly produce pain in PH and trigeminal-autonomic reflex explains the occurrence of autonomic features. Recently, a "permissive" central role of the hypothalamus is unveiled based on functional imaging studies. Other Cox-2 inhibitors, topiramate, calcium-channel blockers, epicranial nerve blocks have been shown to improve headache in some patients of PH who cannot tolerate indomethacin. Hypothalamic deep brain stimulation has been used in treatment-refractory cases.
Topics: Cluster Headache; Headache; Headache Disorders; Humans; Paroxysmal Hemicrania; Trigeminal Autonomic Cephalalgias
PubMed: 34003159
DOI: 10.4103/0028-3886.315982 -
Neurology India 2021Key structures for the pathophysiology of primary headache disorders such as migraine, cluster headache, and other trigeminal autonomic cephalalgias were identified by... (Review)
Review
BACKGROUND
Key structures for the pathophysiology of primary headache disorders such as migraine, cluster headache, and other trigeminal autonomic cephalalgias were identified by imaging in the past years.
OBJECTIVE
Available data on functional imaging in primary headache disorders are summarized in this review.
MATERIAL AND METHODS
We performed a MEDLINE search on December 27, 2020 using the search terms "primary headache" AND "imaging" that returned 453 results in English, out of which 137 were labeled reviews. All articles were evaluated for content and relevance for this narrative review.
RESULTS
The structure depicted most consistently using functional imaging in different states of primary headaches (without and with pain) was the posterior hypothalamus. Whole-brain imaging techniques such as resting-state functional resonance imaging showed a wide-ranging association of cortical and subcortical areas with human nociceptive processing in the pathophysiological mechanisms underlying the different TACs. Similarities of distinct groups of primary headache disorders, as well as their differences in brain activation across these disorders, were highlighted.
CONCLUSION
The importance of neuroimaging research from clinical practice point of view remains the reliable and objective distinction of each individual pain syndrome from one another. This will help to make the correct clinical diagnosis and pave the way for better and effective treatment in the future. More research will be necessary to fulfill this unmet need.
Topics: Cluster Headache; Functional Neuroimaging; Headache; Humans; Migraine Disorders; Trigeminal Autonomic Cephalalgias
PubMed: 34003144
DOI: 10.4103/0028-3886.315987 -
European Journal of Neurology Jul 2021Many clinicians lack experience in managing trigeminal autonomic cephalalgias (TACs) in pregnancy and lactation. In addition to cluster headache, TACs include hemicrania... (Review)
Review
Many clinicians lack experience in managing trigeminal autonomic cephalalgias (TACs) in pregnancy and lactation. In addition to cluster headache, TACs include hemicrania continua, paroxysmal hemicrania, and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing/autonomic symptoms (SUNCT/SUNA). Treating these rare, severe headache conditions often requires off-label drugs that have uncertain teratogenic potential. In the last few years, several new treatment options and safety documentation have emerged, but clinical guidelines are lacking. This narrative review aimed to provide an updated clinical guide and good clinical practice recommendations for the management of these debilitating headache disorders in pregnancy and lactation.
Topics: Breast Feeding; Cluster Headache; Diagnosis, Differential; Female; Humans; Pregnancy; SUNCT Syndrome; Trigeminal Autonomic Cephalalgias
PubMed: 33852763
DOI: 10.1111/ene.14864 -
Headache Apr 2021Paroxysmal hemifacial pain (PHFP) is the orofacial counterpart to paroxysmal hemicrania headaches. This paper reports the cases of two patients suffering from episodic...
Paroxysmal hemifacial pain (PHFP) is the orofacial counterpart to paroxysmal hemicrania headaches. This paper reports the cases of two patients suffering from episodic attacks of severe unilateral facial pain. In both cases, pain attacks were absolutely responsive to therapeutic doses of indomethacin. Both patients were diagnosed with PHFP, as per the International Classification of Orofacial Pain diagnostic guidelines. The diagnosis of PHFP, and a trial of indomethacin, must be considered in cases of severe unilateral facial pains not clearly explained by more common diagnoses.
Topics: Adult; Aged; Anti-Inflammatory Agents, Non-Steroidal; Facial Pain; Female; Humans; Indomethacin; Male; Patient Acuity; Treatment Outcome
PubMed: 33848370
DOI: 10.1111/head.14104 -
Children (Basel, Switzerland) Feb 2021Paroxysmal Hemicrania is a rare form of primary headache in children and adolescents, belonging to the group of trigeminal autonomic cephalalgias. Patients suffer from...
Paroxysmal Hemicrania is a rare form of primary headache in children and adolescents, belonging to the group of trigeminal autonomic cephalalgias. Patients suffer from severe, short-lasting unilateral headaches accompanied by symptoms of the autonomic system on the same side of the head. The short duration of attacks distinguishes Paroxysmal Hemicrania from other trigeminal autonomic cephalalgias. Indomethacin is the treatment of choice, and its effectiveness provides a unique diagnostic criterion. However, the long-term outcomes in children are highly underreported. In this case-series, = 8 patients diagnosed with Paroxysmal Hemicrania were contacted via telephone 3.1 to 10.7 years after initial presentation. A standardized interview was conducted. = 6 patients were headache-free and no longer took indomethacin for 5.4 ± 3.4 years. The mean treatment period in these patients was 2.2 ± 1.9 years. Weaning attempts were undertaken after 1.7 ± 1.3 months; in = 3 patients, more than one weaning attempt was necessary. = 2 patients were still taking indomethacin (4.5 and 4.9 years, respectively). Both unsuccessfully tried to reduce the indomethacin treatment (two and six times, respectively). Adverse effects appeared in = 6 (75%) patients and led to a discontinuation of therapy in = 2 patients. Our long-term follow-up suggests that in a substantial proportion of pediatric patients, discontinuing indomethacin therapy is possible without the recurrence of Paroxysmal Hemicrania.
PubMed: 33546261
DOI: 10.3390/children8020101 -
Journal of Vascular Surgery Cases and... Dec 2020A 70-year-old woman presented to our emergency department with a severe left-sided headache. The headache's location and accompanying symptoms are consistent with...
A 70-year-old woman presented to our emergency department with a severe left-sided headache. The headache's location and accompanying symptoms are consistent with paroxysmal hemicrania. On workup, a cervical computed tomography scan incidentally revealed a left carotid body tumor, and the patient was referred to vascular surgery. After the resection of the tumor, the patient recovered well in the following months. Furthermore, she no longer experienced any additional headache episodes, which were likely caused by the carotid body tumor.
PubMed: 33134628
DOI: 10.1016/j.jvscit.2020.08.004 -
BMC Geriatrics Oct 2020Paroxysmal hemicrania has not been associated with ipsilateral weakness, loss of sensation and Horner's syndrome. This report is the first of its kind documented in...
BACKGROUND
Paroxysmal hemicrania has not been associated with ipsilateral weakness, loss of sensation and Horner's syndrome. This report is the first of its kind documented in literature.
CASE PRESENTATION
This was an elderly, sixty-five-year-old Chinese male who presented with a headache fulfilling criteria of paroxysmal hemicrania and was found to have signs of ipsilateral conjunctival injection, Horner's syndrome, weakness and loss of sensation; with resolution of the patient's physical signs after relief of the headache. Brain magnetic resonance imaging did not show any strokes or other headache mimics. The patient had a marked response to indomethacin and a decrease of headache intensity and frequency with indomethacin prophylaxis.
CONCLUSIONS
Paroxysmal hemicrania has joined the list of stroke chameleons and that it would be one of the differentials in a patient with hemiplegia, hemisensory loss, autonomic signs and severe headache. It suggests that paroxysmal hemicrania in the elderly present atypically.
Topics: Activities of Daily Living; Aged; Brain; Headache; Humans; Indomethacin; Male; Paroxysmal Hemicrania; Stroke; Treatment Outcome
PubMed: 33028219
DOI: 10.1186/s12877-020-01768-5 -
Cephalalgia : An International Journal... Jan 2021Trigeminal autonomic cephalalgias (TACs) are characterized by paroxysmal attacks of unilateral primary headaches associated with ipsilateral craniofacial autonomic... (Review)
Review
INTRODUCTION
Trigeminal autonomic cephalalgias (TACs) are characterized by paroxysmal attacks of unilateral primary headaches associated with ipsilateral craniofacial autonomic symptoms. In this pediatric case series, 13 cases of short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT)/short-lasting unilateral neuralgiform headache with autonomic symptoms (SUNA), including children ages 3-18 years, are discussed. This paper reviews the application of International Classification of Headache Disorders, 3rd edition (ICHD-3) criteria especially in children presenting with SUNCT or SUNA. This is the largest pediatric case series of SUNCT/SUNA reported in the literature.
BACKGROUND
Trigeminal autonomic cephalalgias are rare in children and adolescents, with SUNCT/SUNA having the least reported cases. We will discuss the application of ICHD-3 criteria to diagnose SUNCT/SUNA in children and review overlapping cases and their response to different treatment options including indomethacin, which is typically reserved for specific subtypes of TACs; for example, paroxysmal hemicrania.
CONCLUSION
This case series presents a unique opportunity to aid in the diagnosis and treatment of similar pediatric cases in the future. It helps us to broaden the ICHD-3 criteria to diagnose and treat different overlapping trigeminal autonomic cephalalgia cases in children.
Topics: Adolescent; Child; Child, Preschool; Headache; Headache Disorders; Humans; Paroxysmal Hemicrania; SUNCT Syndrome; Trigeminal Autonomic Cephalalgias
PubMed: 32867532
DOI: 10.1177/0333102420954525