Indomethacin
Trial

Indomethacin is a prescription non-steroidal anti-inflammatory drug (NSAID).
While many NSAIDs are used for pain relief, indomethacin is unique because certain headache disorders respond specifically and robustly to it.

For hemicrania continua and paroxysmal hemicrania, indomethacin is not just a treatment — it is part of the diagnostic process.

The purpose of an indomethacin trial is to answer whether this headache is indomethacin-responsive?

• Complete or relief strongly supports the diagnosis

• No meaningful response makes these diagnoses unlikely

This helps avoid years of ineffective migraine-directed therapy when a different headache disorder is present.

Hemicrania continua

• Continuous, one-sided headache

• Often with autonomic symptoms (tearing, nasal congestion, eye redness)

• Complete response to indomethacin

Paroxysmal hemicrania

• Short, frequent, severe unilateral headache attacks

• Autonomic symptoms

• Complete response to indomethacin

The trial uses stepwise dose escalation over approximately 9 days, unless side effects or clear response occur earlier.

Typical dosing regimen

• 25 mg three times daily for 3 days

• If no clear response →
  50 mg three times daily for 3 days

• If still no response →
  75 mg three times daily for 3 days

Not everyone needs to reach the highest dose. You do not to increase the dose if you have had complete relief.

Gastro-protection

Indomethacin can irritate the stomach lining.

For this reason, it is usually prescribed with a proton pump inhibitor (PPI) to reduce the risk of:

• Stomach pain

• Gastritis

• Ulcers

• Gastrointestinal bleeding

This protection is an important part of a safe trial.

A positive response is typically:

• Rapid and complete improvement, often within days

Partial or modest improvement is less diagnostic and requires careful interpretation.

If you experience clear relief:

• The diagnosis is strongly supported

• Indomethacin may be continued as treatment

• The goal becomes finding the lowest effective dose

Long-term approach

• Reduce to the lowest dose that maintains control

• Long-term use requires monitoring and ongoing risk–benefit discussion

• We will help you decide when it is safe to stop indomethacin, understanding that the headache may return in the future and require further treatment

If there is no meaningful improvement:

• Hemicrania continua and paroxysmal hemicrania become unlikely

• The medication is stopped

A negative trial is still clinically useful, as it helps narrow the diagnosis.

This is common and expected.

If headache:

• Improves clearly on indomethacin

• Returns when the medication is stopped

This further supports an indomethacin-responsive headache disorder and helps guide long-term management decisions.

Options include:

• Staying on the lowest effective dose of indomethacin if it is well tolerated

• Using indomethacin during periods of attacks and abstaining during remission

Not everyone experiences side effects, but possible effects include:

• Stomach pain or heartburn

• Nausea

• Dizziness or lightheadedness

• Headache different from baseline

Taking indomethacin with food and with gastro-protection reduces risk.

Indomethacin may be avoided or used cautiously in people with:

• History of stomach ulcers or bleeding

• Significant kidney disease

• Certain cardiovascular conditions

• NSAID intolerance

We will review this before starting a trial.