Bilateral paroxysmal hemicrania or bilateral paroxysmal cephalalgia, another novel indomethacin-responsive primary headache syndrome?

EDITORIAL Bilateral paroxysmal hemicrania or bilateral paroxysmal cephalalgia, another novel indomethacin-responsive primary headache syndrome? Bingel and Weiller (1) report a case of short-lasting, frequent, bilateral, indomethacin-responsive headache without cranial autonomic features in this issue of Cephalalgia. They consider this to be a bilateral form of paroxysmal hemicrania (PH). We note two other case reports of short-lasting, frequent, bilateral, indomethacin-responsive headaches without cranial autonomic features that have been presented as bilateral PH (2, 3). These three case reports pose an interesting question with regard to their classification: do they represent a bilateral form of PH or are they cases of another novel indomethacin-responsive primary headache syndrome? PH usually begins in adulthood at the mean age of 34 years and a range of 6–81 years (4). The condition predominates in females by a sex ratio of 1.6– 2.4 : 1 (4–6). The clinical phenotype of PH is highly characteristic (4–8). The headache is strictly unilateral and without side shift in the majority of patients. The maximum pain is most often centred on the ocular, temporal, maxillary and frontal regions. The pain is described as a sharp, throbbing, stabbing, aching or boring sensation. The pain is typically excruciating in severity. The headache usually lasts 2–30 min, though can go on for up to 2 h. Attacks of PH invariably occur in association with ipsilateral cranial autonomic features. Lacrimation, conjuncti-val injection, nasal congestion, or rhinorrhoea frequently accompany the headache; eyelid oedema, ptosis, miosis and facial sweating are less frequently reported. Interestingly, there is a case description of a patient with otherwise typical PH, including a good indomethacin response, with no autonomic features (9). In addition, there are two further case reports of patients who had PH without cranial auto-nomic features though it is not clear whether these patients responded to indomethacin (6). Photopho-bia and phonophobia frequently accompany attacks, although nausea and vomiting are less common (6). There is one case report of a typical migrainous aura occurring in association with PH attacks (10). During episodes of pain, approximately half the sufferers prefer to sit or lie still while the other half assume the pacing activity usually seen with cluster headaches (5, 6). The attacks occur at a high frequency, ranging from two to 40 daily. The attacks occur regularly throughout the 24-h period without circadian periodicity or a preponderance of nocturnal attacks. However, nocturnal attacks associated with rapid eye movement (REM) phase of sleep …