Indomethacin Responsive Headache Syndrome
Table 1 from Dodick
- Trigeminal-autonomic cephalgias
- Paroxysmal hemicranias
- Chronic paroxysmal hemicrania
- Episodic paroxysmal hemicrania
- Hemicrania continua
- Valsalva-induced headaches
- Primary cough headache
- Primary exertional headache
- Primary headache associated with sexual activity(preorgasmic and orgasmic)
- Primary stabbing headache (ice pick headache, or "jabs and jolts syndrome")
- Hypnic headache
- Hemicrania continua
Paroxysmal Hemicranias
- Moderate intensity but exacerbations of severe pain, persistent, unilateral orbital, supraorbital and/or temporal pain always on same side
- 2-45 min
- More than 5 per day but periods of lower frequency may occur
- One of the following on the symptomatic (ipsilateral) side during exacerbations: (1) conjunctival injection, (2) lacrimation, (3) nasal congestion, (4) rhinorrhea, (5) ptosis and/or miosis, (6) eyelid edema
Indomethacin Regimen
25 mg tid with meals (may increase to 50 mg tid)
Indocin SR 75 on a daily basis (for up to 3 months, then taper), qD, BID, TID, or QID as tolerated and necessary. 300 mg/day is maximum He should be on as little as possible while still controlling his pain. A little stomach protection and taking it with meals, doesn't hurt. PROTON PUMP INHIBITOR: omeprazole 20-40 mg once daily (Prilosec OTC is 20 mg omeprazole long acting), lansoprazole 15-30 mg once daily (Prevacid 24HR 15 mg), pantoprazole 20-40 mg once daily). I would keep him on it at least three months, and if he is pain-free, start tapering him on a weekly basis by one pill and see how he does.
Goadsby indomethacin regimen as quoted in PRACTICAL NEUROLOGY (Jan/Feb 2012): 25 mg TID for 5-7 days; if ineffective 50 mg TID for 5-7 days; if ineffective 75 mg TID for 2 weeks. (rare reports of response at 300 mg/d) This extended titration schedule avoids missing slow responders although most respond quickly.
Can use indomethacin 75 mg SR bid, which helps with compliance.
Side effects of indomethacin: abdominal pain, dizziness, nausea and/or vomiting, diarrhea, ulcer disease, renal impairment, adverse CV thrombotic events.
Indocin SR 75 on a daily basis (for up to 3 months, then taper), qD, BID, TID, or QID as tolerated and necessary. 300 mg/day is maximum He should be on as little as possible while still controlling his pain. A little stomach protection and taking it with meals, doesn't hurt. PROTON PUMP INHIBITOR: omeprazole 20-40 mg once daily (Prilosec OTC is 20 mg omeprazole long acting), lansoprazole 15-30 mg once daily (Prevacid 24HR 15 mg), pantoprazole 20-40 mg once daily). I would keep him on it at least three months, and if he is pain-free, start tapering him on a weekly basis by one pill and see how he does.
Goadsby indomethacin regimen as quoted in PRACTICAL NEUROLOGY (Jan/Feb 2012): 25 mg TID for 5-7 days; if ineffective 50 mg TID for 5-7 days; if ineffective 75 mg TID for 2 weeks. (rare reports of response at 300 mg/d) This extended titration schedule avoids missing slow responders although most respond quickly.
Can use indomethacin 75 mg SR bid, which helps with compliance.
Side effects of indomethacin: abdominal pain, dizziness, nausea and/or vomiting, diarrhea, ulcer disease, renal impairment, adverse CV thrombotic events.