A well-written paper with good references which pertain to the subject. My main objection to this case report is that this is not Paroxysmal hemicrania. PH is unilateral (although the authors note side-switching can occur) and responds absolutely to indocin. Although there is discussion of “hemicrania continua vera” and “non-vera” which means a constant unilateral headache with autonomic symptoms which resembles hemicrania continua but does not respond to indocin. Most of the time this ends up being migraine. (leone, cephalagia, epidemiology of fixed unilateral headaches). There is no such controversy with PH. If a patient does not respond to indocin it is considered atypical and a search for a secondary cause becomes even more important.

I might suggest an alteranative diagnosis. This is an elderly patient with no known GI problems and bilateral headaches after eating, a high ESR and hx of PMR. Indocin was not effective but a long course of steroids was. Although the temporal artery biopsy was negative, this does not always rule out TA. Skip lesions are common in TA so the false negative rate of biopsies is unfortunately high. Poller DN, van Wyk Q, Jeffrey MJ. J Clin Pathol. 2000 Feb;53(2):137-9. I suspect TA is the likely diagnosis, and the pain with eating is from jaw claudication.

Expert in the treatment of headache disorders well published on the subject.