What medication do you consider in patients who cannot take indomethacin or triptans with a diagnosis of Hemicrania Continua?
1) DIAGNOSIS
First, ensure you have the correct diagnosis. If purely unilateral but no convincing and significant ipsilateral cranial autonomic symptoms, the much more likely diagnosis is migraine. Also, consider cervicogenic headache in these cases. Hence, you would treat as migraine. If convincingly hemicrania continua, also ensure you have done neuroimaging to rule out secondary causes.
2) INDOMETHACIN RESPONSE
Can you have an indomethacin non-responsive hemicrania continua? This is controversial. Problem one is that to diagnose hemicrania continua, you need indomethacin response, so how do you diagnose indomethacin non-responsive hemicrania continua? Problem two is that headache diagnoses are clinical, and we have no gold standard beyond the ICHD-3, which again leads to problem one. Of course, further complicating this issue is the problem leading to this question. How do you confirm the diagnosis in a patient with contraindication to indomethacin?
3) INDOMETHACIN ALTERNATIVES
My general approach to this issue is to borrow treatments from cluster headache and migraine, as well as trigeminal neuralgia.
- Note that GammaCore (Non-invasive vagal nerve stimulation) is now approved for use in paroxysmal hemicrania and hemicrania continua, hence if it can be accessed, is a great alternative to indomethacin.
- OnabotulinumtoxinA, CGRP monoclonal antibodies, gepant, amitriptyline, topiramate, divalproex, nerve blocks, verapamil, lithium, SPG block, lamotrigine, gabapentin, carbamazepine, other neuromodulation devices, etc.
- Studies here are limited but there are case reports supporting many of these.
- Same approach as migraine here... start a preventive and trial it for 3 months.
- I personally tend toward using the cluster headache dosing of 300mg monthly for galcanezumab here.
- Another thing often tried is Gliacin/Boswellia as a biosimilar supplement to replace indomethacin. Melatonin is also thought to be a biosimilar option that can replace indomethacin.
- If indomethacin tolerance is the issue, try another NSAID.
I agree with the good answer that Dr. @Dr. First Last has given. If the over-the-counter treatments do not work, I would definitely use the gamma core device which is cleared by the FDA for hemicrania continua and paroxysmal hemicrania.
ALAN RAPOPORT, MD