Hemicrania continua

Since on our ward we are dealing with strokes mainly, there is a tendency to forget basic neurologic knowledge, in particular in emergency settings. This happened recently in the following case: a 43 yo storage worker comes at 2 am into the ER, complaining about 4 months of unilateral headache, non side-shifting, with ugly exacerbations from his usual 4 to 8-9/10. Upon examination you discover a Horner syndrome and some tearing and noserunning. Interestingly he describes unilateral photophobia.

This is not a dissection, neither an SAH. As with all headaches history is the way to get to the truth, and maybe some treatment. Here are some important questions to ask:

  • Does the headache shift side?
  • Is it diurnally fixed?
  • Worse on lying than on standing?
  • Better with rest?
  • Loccally triggerable?
  • Visual disturbance?
  • Nausea/vomiting?
  • Photo-/phono-/osmo-/kinetophobia? Unilateral?
  • What triggers are there?
  • What drugs help? 

In all the trigeminoautonomic cephalagias, you have to get a picture (i.e. MRI)  eventually, but this should not preclude from treatment. Try oxygen 100%, triptans and indomethacin. Our case does have hemicrania continua, which by definition should react to this unique drug – but this is recently doubted.

References: in addition to the above article try the series of Peter Goadsby’s lectures on headache on YouTube.


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