Epicrania fugax: ten new cases and therapeutic 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.

Linear Headache: A Novel Entity or a Variant of Nummular Headache? Clinical Characteristics and Treatment Response in a Series of 16 Patients

OBJECTIVE

Linear headache has been recently described as an episodic or chronic unilateral pain distributed along a fixed linear trajectory, which combines some characteristics of epicrania fugax and nummular headache. The aim of this study was to describe the clinical characteristics and therapeutic response of a series of 16 new patients.

DESIGN

This is an observational study with a series of cases.

SETTING

The study period encompassed June 2014 to June 2019. Demographic, clinical, and therapeutic response data were recorded.

METHODS

We included all consecutive patients who presented pain with the following characteristics: sharply contoured, fixed in size and shape, with linear shape, without movement along a trajectory, and not circumscribed to the territory of any nerve.

RESULTS

Twelve patients were women, and four were men. The mean age at onset was 40.1 years. Pain was described as pressing in seven patients, burning in five, and electric or stabbing in two each. Symptomatic treatment had been used by 13 patients (81.2%), with analgesics being the most frequent treatment used. Thirteen patients received preventive treatment. The response to oral medications and anesthetic blockade was insufficient. OnabotulinumtoxinA was used in six cases, with an optimal (>75%) response observed in half.

CONCLUSION

Linear headache appears to be a distinct headache syndrome from epicrania fugax or nummular headache. Preventive treatment is often required. The drug with the best response was onabotulinumtoxinA.

Epicrania fugax: Report of eight cases with some novel features

Introduction:

Epicrania fugax (EF) is an epicranial headache syndrome characterized by short lasting headache paroxysms which spread in a typical linear/zigzag pattern. The definition of EF has evolved over time, and new phenotypes have been observed in various studies.

Aim:

We present eight cases diagnosed as EF according to the International Classification of Headaches Disorders, 3rd edition criteria and highlight certain novel characteristics which will help in the further categorization of this disorder.

Methods:

We prospectively studied eight cases of EF who presented to our headache clinic from January 2016 to September 2020. Demographic and detailed clinical data were collected and analyzed.

Results:

The mean age of onset of the cohort was 42 ± 10.47 years with a median duration of symptoms being 1 year. There were 5 male and 3 female patients. The mean visual analog scale score was 5.25 ± 1.83. Headache frequency had high intra and interindividual variability. Four patients had a typical spread of pain along the distribution of greater occipital, and supraorbital, nerves. Four patients had an atypical presentation with midline headache, transverse occipital, and bilateral simultaneous hemicranium involvement. Headache paroxysm was followed by a prolonged fixed pain in the same linear distribution in three patients. One patient had ipsilateral redness in the eye. All eight patients required medical intervention with amitriptyline or neuromodulators, five of whom reported a significant reduction in their headache symptoms.

Conclusion:

Our case series highlights a few interesting features which need further exploration with larger studies. Firstly, the atypical distribution of the pain trajectory forces us to dig deeper into the pathogenesis of the disorder. Secondly, our data also suggest a possibility of EF triggered “linear headaches.” EF is a relatively uncommon headache disorder that can be managed easily with neuromodulators but the lack of awareness of the condition often leads to delayed diagnosis.

Paroxysmal headache with extracephalic irradiation: Proposal for a new variant of epicrania fugax in a series of five patients

Background

Epicrania fugax consists of brief paroxysms of pain, which radiate in a line or in zigzag trajectory across the surface of the scalp or the face.

Methods

A prospective, descriptive study was performed in five patients presenting with an epicrania fugax-type pain with extracephalic irradiation.

Results

All patients were women, and the mean age at onset was 59.8 (standard deviation, 10.9). They had unilateral paroxysms of electrical pain starting at a particular point in the head (parietal, n = 3; vertex, n = 1; frontal, n = 1) and rapidly radiating downwards in a lineal trajectory to reach extracephalic regions (ipsilateral limbs, n = 2; shoulder, n = 2; low neck, n = 1) in 1–3 seconds. Pain intensity was moderate or severe. Three patients had nummular headache at the point where the paroxysms originated. One patient had spontaneous remission, and four patients achieved complete or almost complete response with therapy (onabotulinumtoxinA, n = 2; indomethacin, n = 1; amitriptyline, n = 1; lamotrigine, n = 1).

Conclusion

The spectrum of epicrania fugax may include paroxysms with extracephalic irradiation. The propagation of pain beyond the head and the face supports the involvement of central mechanisms in the pathophysiology of this entity.

Epicrania fugax combining forward and backward paroxysms in the same patient: the first four cases

Background

The first description of epicrania fugax (EF) reported brief painful paroxysms that start in posterior regions of the scalp and move forward to reach the ipsilateral forehead, eye, or nose. A backward variation, wherein pain stems from frontal areas and radiates to the posterior scalp, has also been acknowledged. We report four patients with features reminiscent of EF and the coexistence of forward and backward pain paroxysms.

Methods

We considered all patients attending the headache outpatient office at two tertiary hospitals from March 2008 to March 2016. We enrolled four patients with paroxysms fulfilling criteria for EF and a combination of forward and backward radiations.

Results

In all cases, pain paroxysms moved both in forward and backward directions with either a zigzag (n=2) or linear (n=2) trajectory. Three patients presented two stemming points, in the occipital scalp and forehead (n=2) or in the parietal area and eye (n=1), whereas the fourth patient only had a stemming point located in the parietal region. Pain quality was mainly stabbing, and its intensity was moderate (n=1) or severe (n=3). The duration of the paroxysms was highly variable (3–30 seconds), and two patients reported autonomic symptoms.

Conclusion

The clinical picture presented by our patients does not fit with other types of known headache or neuralgia syndromes; we propose it corresponds to a bidirectional variant of EF.

Stress, Coping, and Personality in Patients with Epicrania Fugax, and Their Relation to the Clinical Characteristics of Pain

Objective

The aim of the present work is to analyze certain psychological features in a group of patients diagnosed with Epicrania fugax (EF; that has been recently included in the appendix of the International Classification of Headache Disorders, third edition, beta version), as well as their association with diverse demographic and clinical characteristics of the sample.

Design

Case-control.

Method

Perceived Stress Scale (PSS), Stress Coping (COPE), Big Five Personality Traits (NEO-FFI), Depression (BDI-II), and Trait Anxiety (STAI) were evaluated in 23 patients with EF and 23 matched healthy controls. Differences between EF patients and controls were analyzed using the Mann-Whitney U test. Differences in psychological features as a function of the demographic and clinical characteristics were examined using one-way Analysis of Variance (ANOVA), Mann-Whitney U test, or Pearson's correlations.

Results

The two groups differed significantly from each other in Denial, Trait anxiety, and Depression. Low-frequency epicrania patients scored significantly higher than controls in Perceived stress, Neuroticism, Denial, Self-blame, Trait anxiety, and Depression and higher than high-frequency EF in Venting.

Conclusions

The results initially suggest the absence of substantial differences between patients suffering of EF and healthy controls. On the contrary, low-frequency EF patients show a distinctive "negative (unhealthy) psychological profile," in opposition to high-frequency EF patients. This circumstance highlights the potential need to consider low- frequency EF patients as a target for psychological intervention in combination with the most common medical procedures. Longitudinal studies are necessary to correctly elucidate the influence of these psychological variables on the course of EF.

Epicrania Fugax

Epicrania fugax (EF) is a primary headache of recent description. EF essentially consists of brief paroxysms of pain describing a linear or zigzag trajectory across the surface of one hemicranium, commencing and terminating in the territories of different nerves. The pain of forward EF originates in a particular area of the occipital, parietal or temporal regions and moves anteriorly, whereas the pain of backward EF originates in the frontal area, the eye or the nose and moves posteriorly. Some patients have ocular or nasal autonomic accompaniments, and some have triggers. Between attacks, many patients have continuous or intermittent pain and/or tenderness at the stemming area. Pain frequency is extremely variable and some patients have spontaneous remissions. Preventive therapy is required when the paroxysms are frequent and non-remitting. Neuromodulators, indomethacin, amitryptiline, nerve anesthetic blockades, and trochlear steroid injections have been used in different cases, with partial or complete response.

Facial epicrania fugax: A prospective series of eight new cases

Introduction

Epicrania fugax (EF) is a primary headache whose main feature is the dynamic character of the pain. EF pain typically moves across different dermatomes in a linear or zigzag trajectory. Recently, a facial variant of EF has been described, with the pain starting in the lower face and radiating upwards.

Aim

We report eight patients with an EF-type of pain of facial location and either upward or downward radiation.

Methods

For each patient, we recorded relevant demographic and clinical data. Magnetic resonance imaging (MRI) with fast imaging employing steady state acquisition (FIESTA) was obtained in all cases for the assessment of neurovascular compression of the trigeminal nerve.

Results

There were seven women and one man, and the mean age was 76.1 years (standard deviation, 11.3). Six patients had a paroxysmal pain starting at the lower face and moving upwards, while two patients had downward radiation. The pain always followed a fixed linear trajectory across different dermatomes. All cases had triggers, and pain intensity was consistently severe. Half of the patients had accompanying autonomic features. Neurovascular compression with imprinting over the trigeminal root on the symptomatic side was identified in three patients. All cases responded to antiepileptic drugs, and three had spontaneous remissions.

Conclusions

This series reinforces the facial variant of EF and extends the phenotype with cases of downward radiation. It also contributes to enriching the differential diagnosis of facial pain. Neurovascular compression of the trigeminal nerve may be found in some cases, although a possible pathogenic link needs further research.

Pain Paroxysms With Coronal Radiation: Case Series and Proposal of a New Variant of Epicrania Fugax

OBJECTIVE

We aim to report 4 patients with brief pain paroxysms whose clinical features remind of typical epicrania fugax (EF), except for the direction along a transverse trajectory.

BACKGROUND

EF has been defined as a brief paroxysmal head pain, with stabbing quality, describing a linear or zig-zag trajectory across the surface of one hemicranium.

METHODS

We considered all patients attending the headache outpatient office at 3 tertiary hospitals from March 2008 to December 2015. We identified a total of 4 cases with dynamic pain paroxysms moving in coronal direction.

RESULTS

The mean age at onset was 49 years (range 34-75). All the patients suffered a dynamic pain from parietal or temporal areas to the contralateral ones, crossing the midline in a linear or zig zag trajectory, the entire sequence lasting 2-3 seconds. No triggers were identified. One patient noticed mild interictal tenderness at the stemming point. The frequency of the attacks varied from 2 per week to 1 every 2 months. No underlying disorders were identified by physical and neurological exams and neuroimaging and laboratory tests.

CONCLUSIONS

Our patients presented with a paroxysmal head pain that might correspond to a transverse variant of EF. These observations may not only expand the EF phenotype but also reinforce the distinction between EF and pericranial neuralgias.

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.

Gabapentin in Headache Disorders: What Is the Evidence?

OBJECTIVE

Gabapentin (GBP), originally an antiepileptic drug, is more commonly used in the treatment of pain, including headache disorders. Off-label GBP is used in headache disorders with some success, some failure, and much debate. Due to this ambiguity, a clinical evidence literature review was performed investigating GBP's efficacy in headache disorders.

METHODS

Bibliographic reference searches for GBP use in headache disorders were performed in PUBMED and OVID Medline search engines from January 1, 1983 to August 31, 2014. Based on abstracts read by two reviewers, references were excluded if: GBP was not a study compound or headache symptoms were not studied. The resulting references were then read, reviewed, and analyzed.

RESULTS

Fifty-six articles pertinent to GBP use in headache disorders were retained. Eight headache clinical trials were quality of evidence Class 2 or higher based on American Academy of Neurology criteria. Seven of the eight clinical trials showed statistically significant clinical benefit from GBP in various headache syndromes (though modest affects at times). One study, Mathew et al., had concerns about intention-treat analysis breaches and primary outcomes.

CONCLUSION

Despite the conflicting evidence surrounding select studies, a significant amount of evidence shows that GBP has benefit for a majority of primary headache syndromes, including chronic daily headaches. GBP has some efficacy in migraine headache, but not sufficient evidence to suggest primary therapy. When primary headache treatments fail, a GBP trial may be considered in the individual patient.

Linear interictal pain in epicrania fugax: a reply

This is a reply to the comments on our article "Linear headache: a recurrent unilateral head pain circumscribed in a line-shaped area" published in JHP 2014 Jun 26; 15:45. In the comments, the authors raise a question whether the linear headache (LH) we reported be a linear interictal pain in epicranial fugax (EF), based on a case they reported. We think that the LH is not a linear interictal pain in EF based on our observations and considerations.

Facial pain radiating upwards: could the pain of epicrania fugax start in the lower face?

BACKGROUND

Epicrania fugax (EF) is characterized by painful paroxysms starting in a particular area of the head, and rapidly radiating forwards or backwards through the territories of different nerves. In former clinical descriptions, the pain moved between the posterior scalp (C2) and the frontal or periorbital area (V1), either in forward or backward direction.

METHODS

We report 5 patients with a paroxysmal EF-type pain starting in the lower face (V2 or V3) and radiating upwards.

RESULTS

In each patient, the pain stemmed from the cheek (n = 1), the upper lip (n = 2) or the chin and mandibular area (n = 2), and then moved up to the forehead or the scalp with linear trajectory. Pain intensity was moderate (n = 1) or severe (n = 4), and pain quality was stabbing (n = 2) or electric (n = 3). The duration of attacks was very brief, lasting 1 to a few seconds. Three patients had ocular or nasal autonomic accompaniments, and 3 had triggers.

CONCLUSIONS

There seems to be a facial variant of EF. These observations could not only expand the clinical spectrum of EF but also enlarge the differential diagnosis of facial pain.

Linear headache: a recurrent unilateral head pain circumscribed in a line-shaped area

Background

A headache circumscribed in a line-shaped area but not confined to the territory of one particular nerve had ever been described in Epicrania Fugax (EF) of which the head pain is moving and ultrashort. In a 25-month period from Feb 2012 to Mar 2014, we encountered 12 patients with a paroxysmal motionless head pain restricted in a linear trajectory. The head pain trajectory was similar to that of EF, but its all other features obviously different from those of EF. We named this distinctive but undescribed type of headache linear headache (LH).

Methods

A detailed clinical feature of the headache was obtained in all cases to differentiate with EF, trigeminal autonomic cephalalgias (TACs) and cranial neuralgia. Similarities and differences in clinical features were compared between LH and migraine.

Results

The twelve LH patients (mean age 43.9 ± 12.2) complained of a recurrent, moderate to severe, distending (n = 9), pressure-like (n = 3) or pulsating (n = 3) pain within a strictly unilateral line-shaped area. The painful line is distributed from occipital or occipitocervical region to the ipsilateral eye (n = 5), forehead (n = 6) or parietal region (n = 1). The pain line has a trajecory similar to that of EF but no characteristics of moving. The headache duration would be ranged from five minutes to three days, but usually from half day to one day in most cases (n = 8). Six patients had the accompaniment of nausea with or without vomiting, and two patients had the accompaniment of ipsilateral dizziness. The attacks could be either spontaneous (n = 10) or triggered by noise, depression and resting after physical activity (n = 1), or by stress and staying up late (n = 1). The frequency of attacks was variable. The patients had well response to flunarizine, sodium valproate and amitriptyline but not to carbamazepine or oxcarbazepine. LH is different from EF, trigeminal autonomic cephalalgias (TACs) and cranial neuralgia, but it had couple of features similar to that of migraine.

Conclusions

The clinical picture of LH might be a subtype of migraine, or represent a novel syndrome.

Rare primary headaches

PURPOSE OF REVIEW

Little is known about most disorders classified as rare primary headaches. This review summarizes current knowledge about clinical presentation, pathophysiology, epidemiology and treatment options of rare headache disorders. Increasing public awareness on the different types of rare primary headache disorders may lead to more research and better patient identification and treatment.

RECENT FINDINGS

The International Headache Society updated the classification criteria for primary headache disorders adding some clinical entities and moving others to different parts of the classification.

SUMMARY

Neuroimaging should be performed in all patients suspected to suffer from rare primary headache to rule out secondary causes of headache. Indometacin might have a good therapeutic effect in some of these headache entities, but larger randomized controlled trials are missing.

Ophthalmoplegia starting with a headache circumscribed in a line-shaped area: a subtype of ophthalmoplegic migraine?

Recurrent painful ophthalmoplegic neuropathy (RPON), formerly named ophthalmoplegic migraine (OM), is a rare condition characterized by the association of unilateral headaches and the ipsilateral oculomotor nerve palsy. The third cranial nerve is most commonly involved in the recurrent attacks. But it is still debated whether a migraine or an oculomotor neuropathy may be the primary cause of this disorder. Here, we report an elder patient who had a recurrent ophthalmoplegia starting with an unilateral headache circumscribed in an area shaped in a line linking the posterior-parietal region and the ipsilateral eye. And the headache had couple of features similar to that of migraine, such as past history of recurrent migraine attacks, accompaniments of nausea, vomiting, and phonophobia, response to flunarizine and sodium valproate. We may herein report a subtype of OM but not a RPON. This case report indicates that OM may exist as an entity and some OM may be wrongly grouped under the category of RPON in the current international headache classification.

Epicrania fugax: 19 cases of an emerging headache

OBJECTIVE

Epicrania fugax (EF) is a primary headache of recent description. We aimed to report 19 new cases of EF, and thus contribute to the characterization of this emerging headache.

BACKGROUND

EF is characterized by painful paroxysms starting in a particular area of the head, and rapidly radiating forwards or backwards through the territories of different nerves. The pain is felt in quick motion along a lineal or zigzag trajectory. To date, 47 cases have been published, 34 with forward EF and 13 with backward EF.

METHODS

We performed a descriptive study of all EF cases attending our Headache Unit from April 2010 to December 2012. Demographic and clinical data were recorded with a structured questionnaire.

RESULTS

Overall, there were 12 women and 7 men. Mean age at onset was 51.7 ± 16.2. Fourteen patients had forward EF, while 5 patients had backward EF. Painful paroxysms lasted 1-4 seconds. Pain intensity was usually moderate or severe, and pain quality was mostly electric. Four patients had ocular autonomic accompaniments. Pain frequency was extremely variable, and 7 patients identified some triggers. Between attacks, 13 patients had some pain or tenderness in the stemming area. Thirteen patients required therapy for their pain. Neuromodulators, indomethacin, anesthetic blockades, and steroid injections were used in different cases, with partial or complete response.

CONCLUSION

EF appears as a distinct headache syndrome and could be eventually included in future editions of the International Classification of Headache Disorders.

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.

Epicrania fugax with backward radiation: clinical characteristics of nine new cases

Epicrania fugax (EF) is a novel syndrome, described as a paroxysmal and brief head pain, starting in posterior cranial regions and rapidly spreading forward ipsilateral eye, nose or forehead. Two patients with comparable clinical features stemming from frontal scalp to ipsilateral posterior regions have been recently described and proposed as backward radiation epicrania fugax (BREF). We report a new series of nine BREF and compare their clinical characteristics with 18 forward radiation EF (FREF). Since first description of BREF in February 2010 we have assessed nine patients (four males, five females) with this clinical picture at an outpatient headache office in a Tertiary Hospital. Comparison is established with 18 FREF patients (6 males, 12 females), attended since the publication of first series of EF in March 2008. We found no differences between BREF and FREF, respectively, in age at onset (43.4 ± 13.1 vs. 42.5 ± 17.7 years), female/male ratio (5/4 vs. 12/6), pain intensity (6.9 ± 2.1 vs. 6.8 ± 2.1 in a 0-10 visual analogical scale), duration (7.1 ± 4.9 vs. 5.7 ± 4.3 s) and frequency of episodes per day (7 ± 8.4 vs. 9.9 ± 15.4). Patients in BREF group presented less frequently interictal pain in stemming point (22.2 vs. 55.5%) and accompanying autonomic signs (33.3 vs. 55.5%), but without statistical significance in both the cases. This series reinforces the proposal of EF as a new headache variant or a new headache syndrome. Clinical picture of brief pain paroxysms starting in the anterior scalp and radiating backwards does not fit known headaches or neuralgias and might correspond to a reverse variant of EF, clinical characteristics of which are comparable to FREF.