Hemicrania Continua: Symptoms, Causes and Treatments

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February 3, 2022
November 12, 2021
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Hemicrania Continua: Symptoms, Causes and Treatments

There are hundreds of different kinds of headache disorders, one of the more overlooked and misdiagnosed ones is hemicrania continua (HC). HC in latin means one side of the head always hurts  - and one distinguishing feature of HC is that it is uniquely one-sided.  That is far from the only thing differentiating HC from other headache disorders.  


HC and the TACs


HC is in a category of headaches called the TACs (trigeminal autonomic cephalalgias).  These are all one-sided headaches, and all have both pain symptoms and autonomic symptoms.  Autonomic symptoms are not painful, and are associated with changes in the functions or activity of parts of the body, here specifically it’s parts of the head and face.  Autonomic symptoms include eye tearing, red eye, runny or stuffy sinuses, the pupil becoming larger or smaller than the other pupil, eyelid drooping, flushing, ear fullness or pressure. 


Instead of needing to go into a dark, quiet room, most people with TACs have a sensation of agitation.  They feel the need to move rather than lay down and stay quiet.  The TACs are also unique in that they last variable amounts of time.  Some TACs only last seconds, some minutes, some hours and then there’s hemicrania continua - which lasts continuously.  


Indomethacin 


HC has another unique feature that is part of its diagnostic criteria.  It is treated by a specific medicine - an NSAID anti-inflammatory called indomethacin.  The effect of indomethacin is so potent that we say, “if it goes away with indomethacin it’s HC, if it doesn’t then it’s something else.”


The first step of treatment (and diagnosis) is usually what’s called an “indomethacin trial”.  The dosage necessary to diagnose HC is 150 mg over the course of 24 hours.  Many people actually respond at a lower dose, so the starting dose is generally either a 25 mg tablet three times a day (with food), or an extended release 75 mg capsule.  If you are any less than completely resolved the dose will likely be increased to eventually reach 150mg, up to a maximum of 225 mg daily.  


What if you can’t use indomethacin? 


Unfortunately, not everyone can use indomethacin.  Because it is a very potent NSAID anti-inflammatory, it can cause gastritis and worsen heartburn.  In extreme cases it can cause a gastric ulcer.  People who are on blood thinners may not be able to take it, as well as people with kidney disease or who are at a high risk of falling.  


Other medications used for either migraine or cluster headache are used in these cases.  We don’t have a treatment as definitively as helpful as indomethacin for this situation, but many of these medications can help the situation significantly.  


Some nerve blocks can be helpful as well, especially one called a sphenopalatine ganglion nerve block.  This “ganglion”, or bundle of nerves, is what causes the autonomic symptoms once activated.  Targeting this ganglion over time may be an effective low risk treatment for people with HC who can’t take indomethacin.

If you struggle with Hemicrania Continua and can't access the specialist who can provide you with the necessary treatment, join Neura Health and get the help you need.


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Thomas Berk, MD
Thomas Berk is Medical Director at Neura Health and a Clinical Assistant Professor at the Department of Neurology at NYU Grossman School of Medicine
About the Author
Dr. Thomas Berk is Medical Director of Neura Health and a neurologist and headache specialist based in New York City. He has over 12 years of clinical experience, having graduated from the NYU Grossman School of Medicine in 2010. He completed his neurology residency at NYU as well and is a board-certified headache specialist, having completed a headache fellowship at the Jefferson Headache Center. He is an emerging leader of the American Headache Society and has been on the Super Doctors list of rising stars for the past five years.

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