Disclosures: Brittany Mays, MD: No financial relationships or conflicts of interest

Case Description: Patient presents 4 months after a motor vehicle accident with left frontal headache that radiates throughout the left temporooccipital region. He experiences baseline headache rated as 6/10 with 2 exacerbations daily rated 10/10. He has associated tearing of the left eye, conjunctival injection, and rhinorrhea. He was seen by neurology who started an indomethacin trial. Patient reported 100mg of indomethacin completely eliminated the pain, thus confirming the diagnosis of HC. However, patient required hospitalization due to upper gastrointestinal (GI) bleed likely secondary to indomethacin. Since indomethacin could no longer be used, he was referred to PM&R neurotoxin clinic for consideration of IncobotulinumtoxinA injections. A trial of IncobotulinumtoxinA was initiated utilizing the PREEMPT fixed site, fixed dose pattern for a total of 100 units.

Setting: Outpatient Physical Medicine and Rehabilitation (PM&R) Neurotoxin Clinic

Patient: A 77 year old male with Post-traumatic Hemicrania Continua (HC)

Assessment/Results: Following 2 cycles of IncobotulinumtoxinA, patient reported the severity of his daily baseline headache decreased to 0/10. The number of exacerbations decreased from 2 times daily to 1-2 per month with a peak intensity of 5/10. Patient reported significant functional improvement and he was able to participate in activities previously precluded by the severity of his symptoms.

Discussion: HC is characterized by a unilateral headache with at least 1 cranial autonomic symptom including: conjunctival congestion, nasal congestion, eyelid edema, facial sweating. To also fulfill the criteria, the patient’s headache must respond to therapeutic doses of indomethacin as was seen in this case. As physiatrists it is important to recognize HC as 22% of reported cases were secondary to post-traumatic etiology.

Conclusion: When formulating differential diagnoses for post-traumatic headache, HC should be considered if cranial autonomic symptoms are present. This case supports the use of IncobotulinumtoxinA for HC when indomethacin is contraindicated and may be considered for refractory cases moving forward.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/incobotulinumtoxina-intervention-for-post-traumatic-hemicrania-continua-a-case-report/