Case: Constant Headache
Case Study: Headache – Case #3
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“For 5 years I’ve had this constant headache, nearly every day. Sometimes it gets so bad I can’t do anything, and I cant’ find anything that gives me relief.”
Case #3: JG is a 54-year-old Hispanic male who presented with chronic daily headache over the preceding 5 years. The patient had had mild chronic low back pain, mild sleep disorder, heartburn, and chest pain that were evaluated as noncardiac in the past. Otherwise patient related an active and healthy life except for chronic daily headache. Patient’s headaches would vary in intensity: located almost entirely on the right side, though occasionally becoming generalized at worst intensity with throbbing or pulsating pain. Mostly, pain was described as a constant pressure that waxed and waned with occasional bouts of rapid shooting pain. At the most severe intensity, pain would be near or completely incapacitating. His headache could be moderately severe with moderate pain at least 20 days out of the month and at least mild headache present continuously. He did occasionally have some nasal congestion and tearing with his headache, questionable more on the right side. He knew of no particular risk factors or aggravating factors to his headache. He found nothing that would relieve his headache pain in terms of analgesics, including hydrocodone, as well as over-the-counter analgesics. He did relate a rash taking naproxen in the past but had been able to take ibuprofen. He had no significant nausea with his headache but did feel that he had some increased sensitivity to odor during the more severe headache. He related no weakness, syncope, or progressive neurological symptoms. Patient did have a CT scan and neurological evaluation with no evidence of acute or malignant process on the scan and normal physical examination.
Past medical history and family history otherwise unremarkable except as already stated.
What would you do next for JG?
Published on April 22, 2010
Updated on April 26, 2010
Discussion
Healthy appearing 54-year-old with chronic daily headache that started out as a chronic daily headache essentially unilaterally, which waxed and waned at various times. Patient did relate some migrainous characteristics to his headache pattern. He did occasionally have some nasal congestion and tearing with his headache, questionable more on the right side. In light of this, patient was treated as probable hemicrania continua with indomethacin starting out at 25 mg tid and subsequent increase to 50 mg tid with virtually total resolution of his headache. Over the next several months he was able to reduce the indomethacin down to 25 to 50 mg daily which continued to keep the headache away.
Summary of the Headache Cases
The 3 headache cases have in common a headache syndrome occurring de novo or in association with another headache syndrome but from the onset or within a few days becoming daily and unrelenting. They also all had marked response to indomethacin having failed other NSAID therapy. They had many of the characteristics described by Medina and Diamond (Cluster headache variant: spectrum of a new headache syndrome. Arch Neurol. 1981;38(11):705-709). Multiple articles have been written over the past years regarding this syndrome and variations of the same. Questions have been asked concerning whether bilateral headaches that start as daily headaches are variant of hemicrania continua or represent a different headache syndrome. The commonality has been the response to indomethacin. Reports have been made of similar type headaches which have not responded indomethacin. Indomethacin however still remains in the diagnostic criteria for hemicrania continua until better understanding of these less frequent headache disorders unveils itself. This reinforces the rationale of trying indomethacin in any chronic daily headache not responding to “standard therapy” as put forth by Solomon and Newman (Chronic daily bilateral headache responsive to indomethacin. Headache. 2007;39(10):754-757). This is especially true for headaches that start as daily headaches without obvious causality.
The 3 case histories mainly address the possibility that a headache that begins from its onset or within a few days as an unrelenting chronic daily headache without obvious reason or history to support transformational migraine, post traumatic headache syndrome, post infectious headache syndrome, or other secondary etiology is more likely to respond to indomethacin. Certainly these patients require thorough evaluation, but especially if they have failed other therapy, a consideration of a trial of indomethacin is recommended unless there is contraindication.
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