Headache Treatments
Michael A. Rogawski, M.D., Ph.D.
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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

Primary Headache Disorders Responsive to Indomethacin with Dosing

Picture
​Villar-Martínez MD, Moreno-Ajona D, Chan C, Goadsby PJ. Indomethacin-responsive headaches-A narrative review. Headache. 2021 May;61(5):700-714. doi: 10.1111/head.14111. PMID: 34105154.

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.