Diagnosis:
Clinical:
- Always unilateral. Usually periorbital pain. M>F
- +15-180 minutes, multiple times per day for weeks
- +long (month) headache free period
- +associated with ipsilateral autonomic features:
- Conjunctival injection or lacrimation
- Nasal congestion or rhinorrhea
- Ptosis or miosis
- Eyelid or forehead swelling
Treatment:
Acutely:
- 100% Oxygen inhaled, 7-10 L/min for 15 min (strong evidence base)
- Sumatriptan 6 mg, sc (strong evidence base), Sumatriptan 20 mg nasal (strong evidence base, but has side effects)
- Zolmitriptan 5 mg nasal (strong evidence base), Zolmitriptan 10 mg oral (moderate evidence base but has side effects)
- Lidocaine nasal (moderate evidence base)
- Octreotide (moderate evidence base)
- Dihydroergotamine
- Consider Prednisolone 60 mg & taper (then 40mg, 20mg over two days or over 3 weeks)
- Avoid pizotifen and intranasal capsaicin because of side effects
Prophylaxis:
- Verapamil (strong evidence base)
- Steroids (strong evidence base)
- Lithium carbonate TID, monitor levels (moderate evidence base)
- Methysergide (moderate evidence base)
- Topiramate (moderate evidence base)
- Ergotamine tartrate or Dihydroergotamine (moderate evidence base)
- Valproic acid (weak evidence base)
- Melatonin (weak evidence base)
- Baclofen 15-30 mg(weak evidence base)
if chronic rather than episodic consider diagnosis of hemicrania continua.