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.

  • A.

    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

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May 3, 2021 | Posted by in NEUROLOGY | Comments Off on Trigeminal Autonomic Cephalalgias: Treatment
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