Paroxysmal hemicrania: diagnosis and treatment

What is it?

Paroxysmal hemicrania is a trigeminal autonomic cephalalgia (TAC). It is not a form of ordinary migraine, despite the potentially confusing Italian terminology.

How it presents

Unilateral pain

Typically orbital, supraorbital or temporal, very intense and clearly confined to one side.

Brief, repeated attacks

Attacks are shorter and generally more frequent than in cluster headache.

Autonomic signs

Tearing, nasal congestion, a runny nose, ptosis or other autonomic symptoms on the same side may accompany the pain.

Indometacin

A complete response to indometacin is one of the most characteristic diagnostic features.

Differential diagnosis

The main distinction is from cluster headache, SUNCT/SUNA, trigeminal neuralgia and other forms of brief unilateral pain. Attack duration and frequency are essential.

Treatment

Indometacin is the reference treatment. Alternatives may be considered for patients with contraindications or poor tolerability, but the supporting evidence is generally weaker.

The role of interventional pain management

In paroxysmal hemicrania, an accurate diagnosis comes before any procedure, and the response to indometacin remains central to the assessment. Interventional pain management is therefore not a first-line treatment, but may be discussed for selected patients in whom indometacin is not tolerated, is contraindicated or does not provide satisfactory clinical control.

When a clinically evident trigeminal-autonomic component is present, pulsed radiofrequency of the sphenopalatine ganglion (SPG)may be considered. This neuromodulation technique is reserved for carefully selected cases and is not a standard treatment for paroxysmal hemicrania. Where appropriate, target selection may be supported by the response to a transmucosal SPG diagnostic test, interpreted alongside the clinical phenotype and the response to reference treatments.