Objective:

N/A

Background:

Hemicrania continua requires specific diagnostic and therapeutic treatment with indomethacin. However, this medication’s unfavorable side effect profile often precludes its long-term use. There are few effective alternative treatments in existence.

Design/Methods:

Results:

A 64 yo male with a history of HTN, GERD, iron deficiency anemia and episodic migraine with aura once a month presented with new-onset continuous, intense, sharp pain located in the left temporal region. In contrast to his usual migraine which stopped occurring right before this pain started, there was no associated nausea, dizziness, visual aura or positive response to triptans. He also denied jaw pain or claudication. ESR was 11 and a contrast-enhanced MRI brain was unremarkable. Treatment with amitriptyline and topiramate was unsuccessful. Autonomic symptoms, which were initially absent, later appeared as ipsilateral periorbital redness, edema and nasal congestion which suggested a trigeminal autonomic cephalalgia. A trial of indomethacin induced near immediate resolution of his symptoms at a dose 50 mg TID, but had to be quickly discontinued due to hematochezia and abdominal discomfort. However, all of his symptoms went into complete remission again within 2 weeks of treatment with botulinum toxin type A (PREEMPT trial protocol with 155 units) repeated every 12 weeks. He continues to be well controlled on this treatment three years on, with occasional breakthrough pain at week 10-11 from the last botulinum toxin injection.

Conclusions: