3.2 Paroxysmal hemicrania

Description:
Attacks of severe, strictly unilateral pain which is orbital, supraorbital, temporal or in any combination of these sites, lasting 2-30 minutes and occurring several or many times a day. The attacks are associated with ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis and/or eyelid oedema. They respond absolutely to indomethacin.

Diagnostic criteria:
A. At least 20 attacks fulfilling criteria B-E
B. Severe unilateral orbital, supraorbital and/or temporal pain lasting 2-30 min
C. At least one of the following symptoms or signs, ipsilateral to the pain:

    1. conjunctival injection and/or lacrimation
    2. nasal congestion and/or rhinorrhoea
    3. eyelid oedema
    4. forehead and facial sweating
    5. forehead and facial flushing
    6. sensation of fullness in the ear
    7. miosis and/or ptosis

D. Attacks have a frequency above five per day for more than half of the time
E. Attacks are prevented absolutely by therapeutic doses of indomethacin1
F. Not better accounted for by another ICHD-3 diagnosis.

Note:
1. In an adult, oral indomethacin should be used initially in a dose of at least 150 mg daily and increased if necessary up to 225 mg daily. The dose by injection is 100-200 mg. Smaller maintenance doses are often employed.

Comment:
In contrast to cluster headache, there is no male predominance. Onset is usually in adulthood, although childhood cases are reported.