Trigeminal Autonomic Cephalalgias: Treatment

Trigeminal autonomic cephalalgias (TACs) encompass a group of primary headache disorders characterized by unilateral headache with ipsilateral cranial autonomic symptoms such as conjunctival injection, lacrimation, nasal congestion, rhinorrhea, facial sweating, miosis, ptosis, and eyelid edema. A sense of restlessness or agitation is often associated with the pain.

In some cases, it may be difficult to differentiate between TACs, particularly when the duration or frequency of the attacks is not clear. Therefore, it is reasonable to consider a 3-week trial of indomethacin ( Table 67.1 ) in patients with unilateral headache associated with ipsilateral cranial autonomic symptoms. Paroxysmal hemicrania and hemicrania continua are by definition prevented absolutely by therapeutic doses of indomethacin, in contrast to cluster headache and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) or short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA).

Table 67.1

Dosing and Titration of Medications for Trigeminal Autonomic Cephalalgias

Drug	Starting dose	Titration	Maximum dose
Indomethacin	25 mg tid	Increase by 25 mg tid every 7 days (discontinue if not effective at maximum dose for 7 days)	225 mg daily
Sumatriptan	4–6 mg SC	Repeat dose if no response in 1 hour	12 mg in 24 hour
Zolmitriptan	5 mg intranasal	Repeat dose if no response in 1 hour	Two doses in 24 hour
Sumatriptan	20 mg intranasal	Repeat dose if no response in 1 hour	Two doses in 24 hour
Dihydroergotamine (DHE)	1 mg IM, SC or intranasal	Repeat dose if no response in 1 hour	3 mg in 24 hour
Intranasal lidocaine	4–10% 1 mL	Repeat once after 15 minutes
Prednisone	60–80 mg	80 mg × 5 days, then decrease by 10 mg every 2 days	Two to three courses/year
Verapamil	80 mg tid (short-acting preferred)	Increase by 80 mg every 10–14 days	960 mg daily
Lithium carbonate	200 mg tid	May increase to 300 mg tid after 7 days	300 mg tid
Topiramate	25 mg qhs	Increase by 25 mg daily every 7 days	200 mg daily
Melatonin	5 mg qhs	Increase by 3–5 mg every week	20 mg daily
Lamotrigine	25 mg daily	Increase by 25 mg q2 week	200 mg bid
Gabapentin	100 mg tid	Increase by 100–300 mg every 4–5 days	1200 mg tid
Sodium valproate	250 mg daily	Increase by 250 mg every 7 days	2000 mg daily
Methylergonovine	0.2 mg tid		0.6 mg daily
Ergotamine	2 mg bid