Bifocal Nummular Headache: The First Three Cases

Nummular headache: a case report of remission following ketogenic diet and botulinum toxin type A injections

Nummular headache is an unusual facial pain disorder with no evidence-based therapy recommendations. The ketogenic diet is an alternative therapy that demonstrated to be effective in migraineurs, but it was never used in the setting of nummular headache. We describe a 58-years old female patient with nummular headache successfully treated with a 6-months ketogenic diet and botulinum toxin type A injections. Ketogenic diet could be an effective alternative/complementary therapy in nummular headache patients although more studies are needed to confirm our results.

Epicranial headaches part 2: Nummular headache and epicrania fugax

BACKGROUND

Nummular headache and epicrania fugax are two primary headaches that fall under the heading of epicranial headaches.

METHODS

This article reviews the epidemiological and clinical features of nummular headache and epicrania fugax, proposed pathogenic mechanisms and state-of-the-art management, according to the literature.

RESULTS AND CONCLUSIONS

Nummular headache and epicrania fugax are generally viewed as rare headache disorders, but no population-based epidemiological data are available. Nummular headache is characterized by continuous or intermittent head pain, which remains circumscribed in a round or oval area of the scalp, typically one to six centimeters in diameter. Epicrania fugax manifests with brief paroxysms of pain that move along the surface of the head, following a linear or zigzag trajectory through different nerve territories. Nummular headache and epicrania fugax are mostly primary headaches, but some secondary cases have been reported. The pathogenesis of these headaches is not fully understood. Nummular headache could probably originate in epicranial tissues or adjacent intracranial structures, while the origin of epicrania fugax could be extracranial or intracranial. Diagnostic assessment requires careful examination of the symptomatic areas. Underlying disorders should be excluded by additional investigations, including neuroimaging and appropriate blood tests. No controlled clinical trials have been conducted in nummular headache or epicrania fugax. Analgesics and anti-inflammatory drugs, botulinum toxin and gabapentin are currently the most recommended treatment options for nummular headache. In epicrania fugax, the most used treatments are gabapentin, lamotrigine, and other antiseizure medications.

Characteristics and treatment effectiveness of the nummular headache: a systematic review and analysis of 110 cases

Background/objective

Nummular headache (NH) is a primary headache disorder characterised by intermittent or continuous scalp pain, affecting a small circumscribed area of the scalp. As there are limited data in the literature on NH, we conducted this review to evaluate demographic characteristics and factors associated with complete resolution of the headache, and effectiveness of treatment options.

Methods

We performed a systematic review of cases reported through PubMed database, using Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol and 'nummular headache', 'coin-shaped headache' and 'coin-shaped cephalalgia' keywords. Analysis was performed by using χ² test and Wilcoxon rank-sum test. For individual interventions, the response rate (RR%) of the treatment was calculated.

Results

We analysed a total of 110 NH cases, with median age 47 years and age of pain onset 42 years. Median duration to make correct diagnosis was 18 months after first attack. The median intensity of each attack was 5/10 on verbal rating scale over 4 cm diameter with duration of attack <30 min. Patients with NH had median three attacks per day with frequency of 9.5 days per month. 40 (57.97%) patients had complete resolution of the headache after treatment. Patients with complete resolution were younger, more likely to be female, and were more likely to have diagnosis within year. Patients with complete resolution more likely to have received treatment with onabotulinum toxin A (botulinum toxin type A (BoNT-A)), and gabapentin compared with patients without complete resolution. Most effective interventions were gabapentin (n=34; RR=67.7%), non-steroidal anti-inflammatory drugs (NSAIDs) (n=32; RR=65.6%), BoNT-A (n=12; RR=100%) and tricyclic antidepressant (n=9; RR=44.4%).

Conclusion

Younger patients, female sex and early diagnosis were associated with complete resolution. NSAIDs, gabapentin and BoNT-A were most commonly used medications, with significant RRs.

Nummular Headache - a Case Report of a Rare Entity

PURPOSE OF REVIEW

The purpose of this manuscript is to shed light on systematic work-up of a diagnostic challenge such as nummular headache (NH), and to summarize the relevant literature on NH.

RECENT FINDINGS

The specific nature of the shape of the pain site is usually characteristic of NH. Multiple modalities of investigation including succinct imaging are necessary to successfully rule out other similar conditions. A 26-year-old female patient of Asian-Indian origin presented to the clinic with the chief complaint of chronic persistent left parietal headache for more than 10 years, which has been worsening over the past few days with no specific identifiable trigger. The diagnosis of nummular headache is challenging and confusing due to the rare occurrence and inadequate references in the literature. Appropriate imaging was done, which revealed no pathology that could explain the headache presentation. These findings are consistent with our diagnosis of nummular headache, and helped in the successful management of the case.

Observational, open-label, non-randomized study on the efficacy of onabotulinumtoxinA in the treatment of nummular headache: The pre-numabot study

Background

Nummular headache is a primary headache characterised by superficial, coin-shaped pain. Superficial sensory fibre dysfunction might be involved in its pathophysiology. Considering the mechanism of action of onabotulinumtoxinA, it could be a reasonable option in treatment of nummular headache. The aim of the study was to evaluate the efficacy and tolerability of onabotulinumtoxinA in a series of nummular headache patients.

Patients and methods

This was an observational, prospective, non-randomized and open-label study. Nummular headache patients with at least 10 headache days in three preceding months were included. They were administered 25 units of onabotulinumtoxinA. The primary endpoint was the decrease of headache days per month, evaluated between weeks 20 to 24, compared with baseline. The secondary endpoints included reduction of intense headache days and acute treatment days evaluated between weeks 20–24 and weeks 8–12, compared with baseline. The 30%, 50% and 75% responder rates were determined, and tolerability described.

Results

We included 53 patients, 67.9% females, with a median age of 54 years. Preventive treatment had been used previously in 60.4% of patients. The median diameter of the nummular headache was 5 cm. At baseline, the number of headache days per month was 24.5 (7.3); the number of intense headache days was 12.5 (10.1), and the number of acute treatment days was 12.8 (7.8). After onabotulinumtoxinA, the mean number of headache days per month decreased to 6.9 (9.3) between weeks 20 and 24 ( p < 0.001). Secondary endpoints concerning intense headache days per month and acute treatment days per month were also statistically significant ( p < 0.001). The 50% responder rate, evaluated between weeks 20 and 24, was 77.4% and the 75% responder rate was 52.8%. Concerning tolerability, 26 patients (49.1%) experienced an adverse event (AE), the commonest being injection-site pain in 12 cases (22.6%). There were no moderate or severe AEs.

Conclusion

It was found that after injecting onabotulinumtoxinA, the number of headache days per month was reduced in nummular headache patients. The number of intense headache days per month and acute treatment days were also lowered. No serious adverse events occurred during treatment.

First three cases of scalp temperature change in symptomatic areas affected by nummular headache: a case report

Background

Nummular headache is a distinct headache disorder characterized by a rounded or elliptical symptomatic area that is typically 2 to 6 cm in diameter and does not change in shape or size with time. Although the pathomechanism is still not clear, nummular headache is thought to be a primary headache disorder. To date, more than 250 cases have been reported; the symptoms of this disease vary, but no cases with scalp temperature changes in the symptomatic areas have been reported yet. In this study, we present three patients with a new manifestation of nummular headache, in which the symptomatic areas of the scalp were colder or warmer than normal areas; we believe that our work might be helpful for medical practitioners and researchers.

Case presentation

The temperature differences between the symptomatic areas and the normal areas were tested in three patients with nummular headache accompanied by changes in scalp temperature. Three patients’ symptomatic areas were either colder or warmer than the normal areas. In every case, we took measurements from the painful site and from the opposite side of the head. The margin of error was 0.01 °C, and the difference was statistically significant (P < 0.01).

Conclusion

We firmly believe that our study will provide an enriched understanding of the variation in clinical manifestations of nummular headache. Our observations might also have clinical implications regarding the pathomechanism of this disease, which remains largely unclear at present.

Nummular headache

Nummular headache (NH) is an unusual disorder attributed to a dysfunction of the epicranial nerves. We report a new series of cases, highlighting some clinical features, the association with other headaches, and the therapeutic response. Data of patients with NH, fulfilling ICHD-3 criteria, observed in a Headache Outpatient clinic during 5 years, were retrieved from records. Response to onabotulinumtoxinA was recorded prospectively and evaluated with a Headache Impact Test (HIT). Twenty-four patients, aged 53.8 (±14.6) years at diagnosis, 13 women, had definitive ( N = 21) or probable ( N = 3) NH for an average of 2.4 years. Headache was consistently localized, more frequently extratrigeminal ( N = 15) and parietal, and confined to the scalp. Pain was unremitting since onset in 58.3% of mild-to-moderate severity often with superimposed paroxysms (66.7%) and local allodynia (70.8%). In five cases, there was a possible precipitant. Thirteen patients reported other headaches, preceding NH by 8.2 years. In eight persistent cases, there was a significant improvement on HIT, after onabotulinumtoxinA. Despite its persistence, NH may go unrecognized for years. It often follows other headache types and has some tropism for hair-covered regions of the scalp. OnabotulinumtoxinA seems effective in persistent cases.

A recurrent headache circumscribed in a coronal line-shaped area around the head: a coronal linear headache

BACKGROUND

Linear headache (LH) has recently been described as a paroxysmal or continuous head pain restricted in a linear trajectory of 5-10 mm in width, linking one endpoint in occipital or occipitocervical region with another endpoint in ipsilateral nasion or forehead region. The sagittal line-shaped pain area of LH is close and parallel to a sagittal venous sinus, the superior sagittal sinus (SSS). For some patients, the LH had some features resembling the pattern of migraine without aura.

CASE DESCRIPTION

A 45 year-old woman complained with a distinct headache for more than half years. The pain trajectory of the headache is confined to a coronal line-shaped area of 5-10 mm in width linking the two points in the bilateral temporal regions with the occipital protuberance. This coronal line-shaped pain area is close and parallel to a coronal cambered venous sinus complex, the combination of the confluences of sinus and the bilateral cavernous sinus (CS), superior petrosal sinus (SPS) linking the CS with transverse sinus (TS) and TS into which the SPS feeds. The patient had a past history of migraine without aura for 10 years and her son had a benign paroxysmal vertigo (BPV) for 12 years. Both of her coronal line-shaped headache and her son's vertigo had well response to sodium valproate.

DISCUSSION AND EVALUATION

Its clinical characteristics were distinctly different from those of other two headache entities defined with topographical criteria, nummular headache and epicrania fugax, and different from other existing headache entities except for migraine without aura.

CONCLUSION

The distinct coronal line-shaped headache is suggestive of a variant of LH, a coronal LH, and probably belongs to a subtype of migraine without aura as proposed for LH. This coronal LH reinforces the proposal of LH as a new headache syndrome or a subtype of a previously known headache syndrome, probably of migraine.

Linear headache: clinical characteristics of eight new cases

Background

Linear headache (LH) has recently been described as a paroxysmal or continuous fixed head pain restricted in a linear trajectory of 5–10 mm in width, linking one endpoint in occipital or occipitocervical region with another endpoint in ipsilateral nasion or forehead region. For some patients, this headache had some features resembling migraine without aura.

Methods

We made a prospective search of patients presenting with a clinical picture comprised under the heading of LH and we have accessed eight new cases. A detailed clinical feature of the headache was obtained in all cases to differentiate with cranial neuralgia, paroxysmal hemicrania, cervicogenic headache, nummular headache and migraine.

Results

The eight LH patients complained of a recurrent moderate to severe, distending, pulsating, or pressure-like pain within a strictly unilateral line-shaped area. The headache duration would be ranged from 1 h to 2 days or persistent for 1–6 months with recurrent worsening of headaches. For some patients, this headache had couple of features similar to that of migraine pattern, such as accompaniments of nausea, vomiting, and phonophobia, diziness, triggering factors of noise, bright night, resting after physical activity, fatigue, menstruation, and response to anti-migraine therapy.

Conclusions

This description reinforces the proposal of LH as a new headache syndrome or a new variant of a previously known headache syndrome, probably of migraine.

Pressure pain sensitivity map of multifocal nummular headache: a case report

Background

Nummular headache (NH) is most commonly a localized unifocal headache; however, some patients infrequently exhibit multifocal symptomatic painful head areas retaining all features of NH. We present the pressure pain sensitivity map of an adolescent with multifocal NH.

Case presentation

We describe a case of a 14 year-old-girl with a 3-year history of continuous pain in four rounded areas, all of them with the same size and shape. Pressure pain thresholds (PPT) were assessed on 21 points over the scalp and over the symptomatic areas. A pressure pain sensitivity map of the head was constructed. The neurological exam was unremarkable, with neither sensory symptoms nor trophic changes within the painful areas. As previously shown, symptomatic points exhibited lower PPTs compared to the surrounding areas. The map reflected 4 restricted areas of mechanical hyperalgesia confined just to the painful areas. Treatment with gabapentin achieved complete remission.

Conclusion

This is the first pain sensitivity map of a patient with multifocal NH. Our results support peripheral mechanisms are maintained in multifocal NH.

Nummular headache: Peripheral or central? One case with reappearance of nummular headache after focal scalp was removed, and literature review

Background

Nummular headache, or coin-shaped cephalagia, is defined as a mild to moderate, pressure-like pain that is felt exclusively in a circumscribed area. More than 200 cases of nummular headache have been reported since it was defined in 2002, but the pathogenesis remains unclear.

Methods

A patient with nummular headache who had the symptomatic area of his scalp removed but suffered headache reappearance was reported. All published cases of nummular headache in the English literature were reviewed and analyzed for demographic and clinical features, image and laboratory findings, and response to treatment.

Results

The patient with nummular headache had the symptomatic area of the scalp removed but suffered reappearance of headache in another area that overlapped with the former one. The literature review showed that nummular headache was a chronic, mild to severe, pressure-like pain with a circular or elliptical shape of 1–10 cm in diameter. The parietal region was the most affected region. Exacerbations and sensory disturbances in the affected area were reported in 43% and 56% of cases, respectively. Observational data suggested botulinum toxin type A (BoNTA) and gabapentin may be beneficial.

Discussion

Our case and evidence from the literature review support the peripheral mechanism of nummular headache. Nummular headache might be a local pain disorder stemming from terminal branches of a sensory nerve and could induce peripheral sensitization in one or several primary sensory neurons.

Nummular headache and epicrania fugax: possible association of epicranias in eight patients

OBJECTIVES

Epicrania fugax (EF) is a novel syndrome presenting with brief pain paroxysms that always start in a particular area of the head to spread immediately either forward or backward. Paroxysms stem from a focal area, in which a well-shaped continuous pain reminiscent of the symptomatic area described in nummular headache (NH) can be present. We aimed to analyze the association of these two epicranial headaches in eight patients.

METHODS

We prospectively assessed all patients with EF attending an outpatient headache office from March 2008, when EF was first described, to June 2012. Among them, we selected those patients with a well-circumscribed continuous pain at the stemming point fulfilling the research diagnostic criteria for NH of the International Classification of Headache Disorders II Edition (ICHD-II) appendix. We considered the demographic and clinical features of the selected patients.

RESULTS

Eight patients (five females, three males) were diagnosed with both EF and NH. Mean age of onset was 44.2 ± 12 (range: 23-60). Regarding NH, the diameter of the painful area was 4.4 ± 1 centimeters (range: 3-6) and pain intensity was 4.2 ± 0.7 (range: 3-5) on a 10-point verbal analogical scale (VAS). As for the EF, the radiating paroxysms always started in the NH painful area and lasted 6.6 ± 4.5 seconds (range: 2-15), with a pain intensity of 7.9 ± 1.6 (range 5-10) on the VAS. Five cases had forward radiation, while three cases had backward EF. Four cases had ipsilateral autonomic accompaniments. Six patients required a preventive, and lamotrigine achieved complete response in three of them.

CONCLUSION

Although the etiology of NH and EF remains uncertain, both syndromes seem to share a peripheral source. Their association in a number of patients is probably reflecting a pathophysiological connection. Lamotrigine might be a good therapeutic option for those patients presenting with both disorders.

[Different headache forms of chapter 4 of the International Headache Classification]

Chapter 4 of the International Classification of Headaches contains a group of clinically very heterogeneous primary headache forms. Little is known about the pathogenesis of these headache types and therapy is usually based on isolated case reports and uncontrolled studies. The forms include primary stabbing headache, primary cough headache, primary exertional headache, primary headache associated with sexual activity, hypnic headache, primary thunderclap headache, hemicrania continua and the new daily persistent headache. Some of these headache forms may be of a symptomatic nature and require careful examination, imaging and further tests. Primary and secondary headache forms must be carefully distinguished.

Nummular headache with and without exacerbations: Comparative characteristics in a series of 72 patients*

Objectives: Apart from the characteristic chronic head pain in a coin-shaped circumscribed area, superimposed exacerbations have been described from early reports of nummular headache (NH). In a prospective series, we aim to compare the demographic and clinical characteristics between cases of exacerbations (ENH) and non-exacerbations (NENH) in NH.

Methods and results: Seventy-two NH patients (44 female, 28 male) attending a headache outpatient office. As eight patients presented with bifocal NH we analysed 80 painful areas; 47 (58.8%) presented in situ exacerbations. Mean intensity of exacerbations was 7.5 ± 1.6 and they lasted 5.7 ± 11.6 minutes. Exacerbation quality was mostly stabbing. We found no differences between ENH and NEHN groups in age at onset, baseline pain intensity, size of painful area, allodynia or other sensory symptoms, or baseline pain quality. There were no differences between populations with respect to relief with symptomatic therapy, requirement of preventative therapy and its response to preventatives.

Conclusion: In situ exacerbations superimposed on baseline pain are frequent in NH and might be included in diagnostic criteria. No statistically significant differences were found between ENH and NENH cases in demographic and nosological characteristics, or needing or response to therapy, but these sample sizes are small.

Pressure pain sensitivity of the scalp in patients with nummular headache: a cartographic study

Nummular headache (NH) is characterized by focal pain fixed within a small round or elliptical area of the head surface. Sensory dysfunction is apparently restricted to the symptomatic area, but a thorough analysis of cranial pain sensitivity has not been performed. Pressure pain sensitivity maps were constructed for 21 patients with NH and 21 matched healthy controls. In each subject pressure pain thresholds (PPT) were measured on 21 points distributed over the scalp. In each patient PPT were also measured in the symptomatic area and at a non-symptomatic symmetrical point. In both groups an anterior to posterior gradient was found on each side, with no significant differences of PPT measurements between sides or groups. In patients with NH, only the symptomatic area showed a local decrease of PPT (significant in comparison with the non-symptomatic symmetrical point, P < 0.001). These findings further support that NH is a non-generalized disorder with a peripheral source.

Epicrania fugax: ten new cases and therapeutic results

OBJECTIVE

We aimed to report 10 new cases of epicrania fugax (EF), showing their clinical features and therapeutic responses.

BACKGROUND

Epicrania fugax has been recently described as a paroxysmal head pain starting in a focal area located at a posterior cranial region and rapidly spreading forward to the ipsilateral eye or nose along a linear or zigzag trajectory. In some patients the pain is followed by ocular or nasal autonomic features. In the prior series, 1 patient got pain relief with anesthetic blockades, while another patient improved with carbamazepine.

METHODS

Since the first description of EF, we have assessed 10 patients with the same clinical picture (8 women and 2 men) at the Neurology outpatient offices of our 2 centers.

RESULTS

The mean age at onset was 48.5 years (SD: 19.8, range: 23-83). All the patients complained of strictly unilateral pain paroxysms starting at parietal (n = 5), occipital (n = 4), or parieto-occipital locations (n = 1), and immediately spreading forward through a linear pathway toward the ipsilateral forehead (n = 3) or the ipsilateral eye (n = 7), the complete sequence lasting 1-10 seconds. No trigger was identified in any of our patients, while 5 of them suffered mild pain in the stemming area between the paroxysms. Three patients had ipsilateral lacrimation, and 2 had conjunctival injection at the end of the attacks. The frequency ranged from 1 attack per week to multiple attacks per day. Neuroimaging and laboratory tests were consistently normal. Interictal pain was responsive to acetaminophen. In 3 cases a preventive was considered in order to avoid the paroxysms. Gabapentin led to significant improvement in 2 cases. The third patient did not obtain any benefit from gabapentin or amitriptyline, but improved slightly with lamotrigine.

CONCLUSIONS

This description reinforces the proposal of EF as a new headache variant or a new headache syndrome. Anesthetic blockades, carbamazepine, gabapentin, and lamotrigine have been apparently effective in individual patients. Further observations and therapeutic trials are needed.