Clinical features of unilateral headaches beyond migraine and cluster headache and their response to indomethacin

Abstract

The majority of previous studies on unilateral headaches beyond migraine and cluster headache have focussed on certain disorders such as paroxysmal hemicrania, SUNCT and primary stabbing headache. We assessed headache characteristics, importance of neuroimaging and response to indomethacin in an unselected series of uncommon unilateral headaches. We investigated all consecutive patients presented with unilateral headaches not fulfilling ICHD-II criteria of migraine and cluster headache. Patients underwent cranial magnetic resonance imaging or computed tomography as well as an indo-test, i.e. oral indomethacin 75 mg b.i.d. for 3 days. Among 63 patients we diagnosed primary stabbing headache in 12 patients, (probable) paroxysmal hemicrania in 6 and tension-type headache in 3 patients. One patient each had probable SUNCT, new daily persistent headache and nasociliary neuralgia. Eight patients had a secondary headache and 31 could not be classified according to ICDH-II. Imaging revealed lesions causally related to the headache in 8 patients. Indo-test achieved full remission of headache in 13 of 51 patients. At follow-up 11 ± 3 months after the first visit 29% of the patients were headache-free for ≥3 months. In conclusion, almost half of the patients presented with unilateral headaches beyond migraine and cluster headache cannot be classified according to ICHD-II. Among classifiable headaches primary stabbing headache was the most common. Imaging should be considered to rule out secondary headaches. The course is favourable in one third of the patients.

Refractory chronic cluster headache: a consensus statement on clinical definition from the European Headache Federation

“…Depression and anxiety disorders represent undisputable co-factors in the progression of CH and require adequate treatment [ 16 ]. Other brain conditions, mainly vascular, should be carefully ruled out by appropriate investigation, including the carotid dissection [ 17 - 19 ]. CCH sufferers often overuse symptomatic medications to treat CH attacks and may develop medication overuse headache (MOH) in addition.…”

“…Behaviours exaggerating CH attacks like alcohol consumption, smoking, taking naps, vasodilating antihypertensives should be avoided [ 21 ]. The indomethacin test is recommended to exclude paroxysmal hemicrania, since there are cases with overlapping clinical pictures [ 17 , 22 ]. Investigation with polysomnography may be useful to exclude several rare conditions that may exaggerate CCH [ 23 , 24 ].…”

Paroxysmal hemicrania: a retrospective study of a consecutive series of 22 patients and a critical analysis of the diagnostic criteria

“…This indicates that PH is probably more common than it was anticipated earlier. Seidel et al [11] reported 63 consecutive patients with unilateral headache not resembling migraine or CH. Only twenty-four patients received a diagnosis of primary headache disorders.…”

“…In the absence of clear cut biological marker, it will be difficult to differentiate borderline or atypical cases of TACs and HC. In Seidel et al [11] case series of 63 consecutive patients with unilateral headache not resembling migraine or CH, only twenty-four patients (38%) received a diagnosis of primary headache disorders. Headaches could not be classified according to present ICHD-II criteria in 49% patients.…”

Are the ICHD‐II Criteria for Hemicrania Continua Too Restrictive?

“…We read with great interest the recent discussion of our paper by Drs. Taylor, Kaniecki, and Landy 1 . We agree that the current International Classification of Headache Disorders 2nd Edition (ICHD‐II) criteria for hemicrania continua (HC) are too strict.…”