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Hemicrania Continua

Continuous unilateral headache with autonomic findings, completely responsive to indomethacin.

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our Nöroloji department. Book Appointment →

What is Hemicrania Continua?

Hemicrania continua (HC) is a primary headache classified within trigeminal autonomic cephalalgias (TAC) group; women:men ratio = 2:1, average age 30-40 years, prevalence 1/1000. Diagnostic criteria (ICHD-3): unilateral pain (no side change, persistent on one side), continuous (>3 months) pain duration, baseline pain mild-moderate severity + at least one of: ipsilateral cranial autonomic feature (conjunctival injection, lacrimation, nasal congestion-rhinorrhea, eyelid edema, ptosis, miosis) or feeling of restlessness/agitation, complete response to therapeutic indomethacin dose.

Two clinical subtypes: continuous form (constant pain), remittent form (pain-free periods + exacerbations). Most patients have superimposed exacerbations on constant pain (severity reaching 7-9/10), 2-15 episodes/day, lasting 30 minutes-3 days. Cranial autonomic findings are seen in 60-90%, particularly during exacerbations. Restless ness/agitation feeling (sense of restlessness) is characteristic.

Differential diagnosis: cluster headache (episodic, severe sharp), paroxysmal hemicrania (episodic, indomethacin response), SUNCT/SUNA (very short duration, autonomic), migraine (variable, often with aura). Indomethacin test is diagnostic: 25-150 mg/day titration, complete response within 24-48 hours = HC diagnosis. Imaging (brain MRI) is mandatory to exclude secondary causes (3-7%): pituitary tumor, mesencephalic lesions, Chiari, vascular pathology, dural sinus thrombosis.

Symptoms

Continuous unilateral headache (>3 months, side does not change)
Baseline mild-moderate pain (3-5/10) + exacerbations (7-9/10)
Frontotemporal-orbital area pain dominant
Cranial autonomic findings (in 60-90%):
- Conjunctival injection
- Lacrimation (tearing)
- Nasal congestion or rhinorrhea (one nostril)
- Eyelid edema
- Ptosis or miosis (Horner-like)
- Forehead-facial sweating
Restlessness, agitation feeling (during exacerbation)
Sometimes accompanying photophobia, phonophobia, nausea (less than migraine)
Worsening with movement
May be triggered by alcohol (in some patients)

Risk Factors

Female sex (2:1)
Middle age (30-40)
Family history (rare, genetic factor unclear)
Migraine history (overlap possible)
Stress, sleep disturbance (trigger)
Alcohol use (some patients trigger)
Posture-positional changes
Rare secondary causes:
- Pituitary tumor
- Mesencephalic infarction-tumor
- Chiari malformation
- Vascular malformation
- Dural sinus thrombosis
- Cervical spondylosis (referred pain)

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Persistent unilateral continuous headache for more than 3 months
  • Same-side persistent pain that does not change side
  • Pain accompanied by autonomic findings (lacrimation, ptosis, nasal congestion)
  • Sleep disturbance due to pain
  • Daily life decline
  • Pain unresponsive to NSAID-triptan
  • Sudden severe headache + new neurologic findings (secondary cause)
  • Pain change after age 50 (red flag)
  • Brain MRI cannot be planned without primary care

Treatment Methods

01
Detailed headache history (location, autonomic findings, side)
02
Brain MRI + cervical MRI + venography (gold standard - secondary cause exclusion)
03
Indomethacin test (definitive diagnosis):
04
- 25 mg 3×/day start, every 5 days +25 mg increase
05
- Maximum 75-225 mg/day (rarely up to 300 mg)
06
- Complete response within 24-48 hours = HC
07
- Maintenance: lowest effective dose (often 50-100 mg/day)
08
Indomethacin protection (chronic use):
09
- PPI co-prescription (omeprazole, pantoprazole)
10
- Renal function follow-up (creatinine)
11
- Cardiovascular risk evaluation
12
Indomethacin alternatives (intolerance, side effect):
13
- Other COX-1 NSAIDs: ibuprofen, naproxen, ketoprofen
14
- Celecoxib (selective COX-2)
15
- Topiramate (50-200 mg/day)
16
- Verapamil (240-360 mg/day)
17
- Gabapentin (300-1200 mg/day)
18
- Melatonin (3-15 mg/night)
19
- Onabotulinumtoxin A (selected)
20
- Occipital nerve block (selected)
21
- Occipital nerve stimulation (refractory)
22
Lifestyle: regular sleep, stress management, trigger avoidance
23
Pregnancy: indomethacin contraindicated - alternative
24
Long-term follow-up: 6-month indomethacin discontinuation attempt (some patients spontaneous resolution)

Which Department to Visit?

You can visit our Nöroloji department for these complaints. Our specialist physicians will create the most suitable treatment plan for you.

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.