What is the role of medications in the treatment of chronic paroxysmal hemicrania (CPH)?

Updated: Jun 12, 2019
  • Author: Monica Saini, MD, MBBS; more...
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The drug of choice in the treatment of chronic paroxysmal hemicrania (CPH) is indomethacin. [21] When a patient experiences frequent, unilateral headaches (ie, >4 attacks in 24 h), a drug trial with indomethacin should be considered. The dose of indomethacin should be increased to at least 150 mg/day for 3-4 days. A beneficial effect is seen usually within 48 hours but may take as long as 5 days.

In one study, indomethacin effect was complete within 24 hours in most patients, and frequently the effect was seen within 8 hours. Maintenance dosage is usually 25-100 mg/day but may range from 12.5-300 mg/day. After discontinuation of medication, symptoms usually reappear within 12 hours to a few days. However, remission periods lasting years have been described.

A significant proportion of patients may experience adverse effects of indomethacin, including dyspepsia, nausea, vomiting, vertigo, gastric bleeding, purpura, and other conditions. To prevent adverse gastric effects, antacids, misoprostol, or an H2 antagonist or proton pump inhibitor may be coadministered when indomethacin is being used for longer periods. An indomethacin suppository is another option for gastric intolerance or when a higher dose (eg, 300 mg/day) is needed.

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