Rare but Critical: Indomethacin-Responsive Headache with Long-Lasting Autonomic Symptoms

Hemicrania with long-lasting autonomic symptoms (LASH), first described in by Rozen 1 , is an extremely rare headache disorder thought to be part of the trigeminal autonomic cephalalgia (TAC) spectrum.However, it is not included in the current International Classification of Headache Disorders, 3 rd Edition (ICHD-3). 2Notably, patients with LASH typically respond well to indomethacin.The condition is characterized by a moderate-to-severe unilateral headache accompanied by prolonged cranial autonomic symptoms, which begin before headache onset, persist for 1-3 days, and continue for some time after headache resolution.Headache attacks last longer than those of typical TACs-often for several hours-and patients remain pain-free between attacks. 3A 32-year-old right-handed man presented with a 2-year history of headache attacks of moderate intensity.These episodes were accompanied by right eyelid edema and ptosis, as well as pruritus in the right eye.The headache lasted only 30-40 minutes, but ipsilateral autonomic symptoms persisted for 1-2 days.The patient did not report associated nausea, vomiting, photophobia, phonophobia, irritability, or restlessness.He denied that chewing, head or neck movements, or facial palpation provoked either headache or autonomic symptoms.Over the 2-year period, he experienced an average of one attack per month, with no other headaches between episodes.His medical history and neurological examination were unremarkable between attacks.Brain magnetic resonance imaging (MRI), MR angiography, and MR venography were all normal.Ophthalmological examination revealed no additional abnormalities.