Indomethacin-intolerant hemicrania continua: treatment with botulinum toxin

Hemicrania continua (HC) is responsive to indomethacin, which is useful both for acute treatment and for chronic suppressive therapy. However, this medication is poorly tolerated in many patients. The treatment of indomethacin-intolerant HC is poorly defined. We present a patient with HC who developed acute kidney injury on indomethacin and proved refractory to multiple other treatment modalities. She had an excellent response to botulinum toxin, with a duration of benefit similar to that reported previously in HC and in chronic migraine. Botulinum toxin may be a therapeutic option in patient with HC who do not tolerate indomethacin. The possible mechanisms of action of botulinum toxin in HC are discussed.