Seasonal Episodic Paroxysmal Hemicrania Responding to Cyclooxygenase-2 Inhibitors

Abstract

Chronic paroxysmal hemicrania (CPH) was first described by Sjaastad who also described a remitting form of this condition (1, 2). This new entity was named episodic paroxysmal hemicrania (EPH) in 1987 by Kudrow (3). It is characterized by brief, frequent attacks of unilateral orbital or temporal pain with associated autonomic symptoms. Most cases respond to indomethacin. A seasonal variant of EPH has been described (4), but never a response to treatment with cyclooxygenase (COX)-2 inhibitors. Case historyA 66-year-old woman presents with a 30-year history of headaches. She describes the pain as severe, occurring three to four times daily over the right temporal, frontal, and parietal region, and lasting 20 min There is associated nasal congestion and lacrimation of the right eye. Two years ago, her headache became seasonal, with cycles in autumn (October) and spring (March). The cycles last two to three months, after which she is pain-free until the next cycle begins. She has hypertension and her son has cluster headaches. Her physical and neurological examinations and a head computed tomography were normal. Various preventive medications, including amitriptyline, propranolol, atenolol, nifedipine, valproic acid and topiramate were of no benefit. The combination analgesic of aspirin, caffeine and butalbital brings minimal relief.Indomethacin was started at 25 mg daily and she became pain free. Routine blood work performed after indomethacin initiation revealed an elevated creatinine level. The medication was discontinued. A nephrologist was consulted and it was agreed that the COX-2 inhibitors could be tried. She was then put on valdecoxib, 10 mg twice a day for nine days with no relief. This was then changed to celecoxib, 200 mg twice a day, from which she obtained substantial but not total relief. She was then switched to rofecoxib and at 50 mg once a day, she became completely pain free. She took rofecoxib for 4 weeks and remained pain free during this time. She then had a repeat creatinine level checked which was again elevated. On advice of her nephrologist, she was taken off rofecoxib and her headaches returned almost immediately. She continued to get headaches which gradually tapered off in intensity and frequency until she went out of cycle two months later.

Prolonged Application of High Fluid Shear to Chondrocytes Recapitulates Gene Expression Profiles Associated with Osteoarthritis

“…The former genes are related to inflammation, matrix degradation and apoptosis. A positive association in the expression levels of COX-2 and caveolin-1 [35], [36] or EPH receptor A2 [37] is supported by findings of other studies employing different cell types. Caveolin-1 and -2 co-localize and form a hetero-oligomeric complex in vivo [38].…”

Italian guidelines for primary headaches: 2012 revised version

“…of casesReferencesIndomethacin25–50C0/++–1[322]Indomethacin75C0/++++Occasional, not severe8[323–330]Indomethacin150C0/++++–2[330, 331]Indomethacin200–225C0/+++Occasional, not severe3[331, 332]Verapamil480C0/+?–1[333]Piroxicam-β-cyclodextrine20–40C0/+++–6[334]Rofecoxib25C0/++++–1[317]Rofecoxib50C0/++++Occasional, not severe2[317, 318]Celecoxib400C0/++++–1[319]Verap...…”

Trigeminal autonomic cephalalgias: A review of recent diagnostic, therapeutic and pathophysiological developments

“…There has been some limited success in the treatment of PH with cyclooxygenase-2 (COX-2) inhibitors, rofecoxib[65–67] and celecoxib. [6768] However, prolonged use of both of these agents has recently been linked with an increased risk of myocardial infarctions and strokes, and this culminated in the withdrawal of rofecoxib from the market worldwide.…”

“…[6768] However, prolonged use of both of these agents has recently been linked with an increased risk of myocardial infarctions and strokes, and this culminated in the withdrawal of rofecoxib from the market worldwide. [69] In view of this, the available COX-2 inhibitors should be prescribed only with great caution in PH.…”