Nummular headache: an update and future prospects

Are there differences between patients with unifocal nummular headache and those who progress to bifocal nummular headache? A retrospective observational study

OBJECTIVES

This retrospective observational cohort study aimed to compare clinical characteristics and treatment responses in patients exclusively experiencing unifocal nummular headache (NH) with those who develop the bifocal variant.

METHODS

A retrospective study was conducted on patients diagnosed with NH who attended a neurology (headache) outpatient clinic between January 2018 and December 2022. The cohort was divided into two groups: Group 1, exclusive unifocal NH; and Group 2, those developing a secondary focal area of pain, i.e., bifocal NH. Data were collected on demographic characteristics, clinical features, other headache comorbidities, and treatment-related information.

RESULTS

A total of 23 patients were included in this study: 12 were categorized as unifocal NH (Group 1) and 11 as bifocal NH (Group 2). There were no differences between the two groups in terms of demographic characteristics, clinical features, or treatment response. Nonetheless, patients with bifocal NH exhibited spontaneous remission rates in the first pain area when compared to the unifocal NH group, with statistically significant differences (36% vs. 0%, p = 0.020).

CONCLUSION

In our sample, patients with bifocal NH demonstrated spontaneous remission rates in the initial pain area, a phenomenon not observed in patients with unifocal NH. It is worth noting the limited sample size in the present study, highlighting the need for larger cohorts to validate and further explore our findings.

Long-term outcomes of nummular headache: A series of 168 patients and 1198 patient-years of follow-up

BACKGROUND

Since the first description of nummular headache (NH), more than 500 cases have been described, delineating its clinical phenotype and response to treatment. However, data on the natural history of NH and outcomes during long-term follow-up are not currently available. The present study aimed to describe the long-term outcomes and follow-up of a large series of patients with NH.

METHODS

A descriptive observational ambisective study with a series of cases was conducted. The study population included adult patients with primary NH and a minimum of 12 months of follow-up. Demographic variables, previous medical history, clinical phenotype, diagnosis and treatment of NH, temporal pattern, and long-term evolution were analysed.

RESULTS

In total, 168 patients were enrolled and followed for a median [interquartile range (IQR)] of 80.5 (55-118.5) months. The temporal pattern after NH onset was chronic in 67.9% and, at diagnosis, the median (IQR) number of pain days per month was 20 [10-30] days with 138 (82.1%) patients with ≥8 days of pain per month. Preventive treatment was needed by 112 (66.7%) patients. The most frequently used drugs were gabapentin (69/112; 61.6%), onabotulinumtoxinA (38/112; 33.9%), amitriptyline (31/112; 27.7%) and lamotrigine (21/112; 18.7%). Response to preventive treatment was at least partial in 91/112 (81.3%) patients. At the end of follow-up, 81 (48.2%) patients had inactive NH. Of patients with active NH, the median (IQR) number of headache days per month was 3 (1-12) days and patients had ≥8 days of pain in 35 (20.8%) cases.

CONCLUSIONS

Long-term outcomes of NH were positive in most patients. After a median of 6.7 years of follow-up, 48% of cases were inactive. Two-thirds of patients required preventive treatment, and 80% of them were treatment-responsive. In NH cases that remained symptomatic, the headache frequency was lower, and the proportion of patients with chronic NH decreased from 68% to 11%.

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.

Epicranial headache part 1: Primary stabbing headache

BACKGROUND/OBJECTIVE

Primary stabbing headache is a common but under-recognized primary headache disorder. The objectives of this review were to provide practical information for better understanding and identification of the disease, suggest an algorithm for differential diagnosis, and provide an insight into the pathophysiology of primary stabbing headache hypothesized from its clinical course.

METHODS

This narrative review of primary stabbing headache is based on a literature search and the authors' clinical reasoning.

RESULT

The phenotype of each stab is typically abrupt, ultrashort-lasting (<3 s), focal or multifocal, paroxysms of pain occurring sporadically or in clusters. The diagnosis of primary stabbing headache is clinical; fixed or migrating stabs without background pain or sensory abnormalities and the absence of features suggestive of other disorders (e.g., cranial autonomic symptoms or signs) can aid in the diagnosis of primary stabbing headache. The clinical patterns include monophasic, intermittent, and chronic primary stabbing headache, of which the first two are considered typical. The pathophysiology of primary stabbing headache has not yet been elucidated. In this review, we postulated the mechanism of stabbing headache, based on the pain phenotype and clinical course, and provide a clinical algorithm for the differential diagnosis of primary stabbing headache.

CONCLUSION

Knowledge about the typical manifestations and clinical patterns of primary stabbing headache will aid in the proper diagnosis and differential diagnosis. Treatment should be tailored by considering the clinical patterns. Further research is needed to elucidate the pathophysiological mechanisms and optimal treatment of primary stabbing headache.

Migraine without aura

Migraine without aura is the commonest form of migraine in both children and adults. The diagnosis is made by applying the International Classification of Headache Disorders Third Edition subsection for migraine without aura (ICHD-3 subsection 1.1). Attacks in patients with migraine without aura are characterized by their polyphasic presentation (prodrome, headache phase, postdromal phase). The symptomatology of attacks is diverse and heterogeneous, with most common symptoms being photophobia, phonophobia, nausea, vomiting, and aggravation of pain by movement. The clinician and researcher who wants to learn about migraine without aura needs to be able to apply the ICHD-3 criteria with its specific symptomatology to make a correct diagnosis, but also needs to be aware about the plethora of symptoms patients may experience. In this chapter, the reader will explore the clinical phenotypical features of migraine without aura.

Treatment of Primary Nummular Headache: A Series of 183 Patients from the NUMITOR Study

Nummular headache (NH) is a primary headache characterized by superficial coin-shaped pain. NUMITOR (NCT05475769) is an observational study evaluating the responder rate of preventive drugs in NH patients. The treatment response was assessed between weeks 8 and 12 compared with the baseline. Patients were included between February 2002 and October 2022. Demographic and clinical variables were assessed; treatment response was estimated by 50%, 30%, and 75% responder rates and treatment discontinuation due to inadequate tolerability. A total of 183 out of 282 patients fulfilled eligibility criteria and completed the study. Patients were aged 49.5 (standard deviation (SD): 16.8) years, and 60.7% were female. NH phenotype was a parietal circular pain of four centimeters' diameter, moderate intensity, and oppressive quality. At baseline, patients had 25 (interquartile range) pain days per month. Preventive treatment was used by 114 (62.3%) patients. The highest 50% and 75% responder rates corresponded to onabotulinumtoxinA (62.5%, 47.5%), followed by gabapentin (43.7%, 35.2%). Oral preventive drugs were not tolerated by 12.9-25%. The present study provides class IV evidence of the effectiveness of oral preventive drugs and onabotulinumtoxinA in the treatment of primary NH. OnabotulinumtoxinA was the most effective and best-tolerated drug, positioning it as first-line treatment of NH.

Nummular and Side-locked Headaches for the Otolaryngologist

Side-locked headaches are a common symptom having a wide-ranging differential. Unchanging in laterality, these headaches can represent neuralgias, trigeminal autonomic cephalgias, ophthalmologic disorders, otolaryngologic and craniofacial disorders, vascular disorders, and malignancy. In rarer situations, they have presented secondary to neurosurgical or dermatologic considerations. Loss of cranial nerves and visual changes warrant additional evaluation.

SECONDARY NUMMULAR HEADACHE: A NEW CASE SERIES AND REVIEW OF THE LITERATURE

BACKGROUND

Nummular Headache (NH) is defined in the International Classification of Headache Disorders (ICHD) by the presence of localized pain circumscribed to a small round area of the scalp, not better accounted by any other diagnosis. As in many other primary headache disorders, secondary cases might occur. To date, 13 secondary cases have been published. We aim to present a long series of secondary NH and review the literature of symptomatic NH.

PATIENTS AND METHODS

Retrospective analysis of an observational prospective cohort in a headache unit located in a tertiary hospital. We included patients that fulfilled ICHD criteria and were attributed to a secondary cause. We describe the clinical characteristics, the underlying causes, and the response to treatment.

RESULTS

We included 274 NH patients, 8 of them (2.9%) were considered secondary. In 1 patient the underlying cause was subcutaneous, as for 6 cases the lesion was located in the bone (two hemangiomas, 1 osteoma, 3 different types of cysts), and in one was intracranial but closely related with internal diploe (cavernoma). Among our patients with secondary NH, a preventive therapy was not always needed and, when required, gabapentin or onabotulinumtoxinA were used with positive response.

CONCLUSION

Secondary NH phenotype overlaps primary NH. Therefore, we recommend routine imaging study in every NH patient. Concerning treatment, it was not necessary to remove the underlying lesion to control the pain and many cases responded to the same prophylactics as primary NH cases.

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.

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.

Nummular Headache and Its Surgical Treatment

Nummular headache (NH) is an uncommon primary headache characterized by pain limited to a precise small area of the scalp. There is no global consensus on its pathogenesis, but its extracranial origin is the most accepted theory. Moreover, peripheral mechanism is supported by the overlapping symptomatology of secondary forms of NH and is well described in the literature. However, a standard effective treatment is still lacking.

METHODS

A literature search according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines was conducted to evaluate surgical strategies for NH. Inclusion criteria were English language, diagnosis of primary NH according to International Classification of Headache Disorders, 3rd Edition, or of secondary NH, and follow-up at a minimum of 3 months. The treatment had to consist of peripheral surgery.

RESULTS

One hundred eighty-seven records were identified after duplicates were removed, 15 full-text articles were assessed for eligibility, and 4 records were selected for inclusion. A total of 53 patients were included in this review, 50 of whom were diagnosed with primary NH. The general positive response after surgery (>50% reduction in occipital migraine headaches) was about 70.0% for primary NH, while secondary NH always showed complete pain relief. However, many variations in patient selection and type of surgery were described.

CONCLUSIONS

Neurovascular relationship in the extracranial tissues seems to be involved in the onset of NH. However, only limited data from meager literature and from few patients are currently available. Shared multicentric research protocols are badly required.

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.

Use of Mindfulness-based Cognitive Therapy to Change Pain-related Cognitive Processing in Patients with Primary Headache: A Randomized Trial with Attention Placebo Control Group

Background

Mindfulness-based interventions have shown to be efficient in managing chronic pain. Cognitive factors play a prominent role in chronic pain complications and negative cognitive contents about pain are often the first issues targeted in cognitive-based therapies, which are known as first-line treatment of chronic pain over the past decades. Little, however, is known about the manner of thinking about pain or pain-related cognitive processing.

Objectives

Therefore, the purpose of this study was to investigate the effect of mindfulness-based cognitive therapy (MBCT) on pain-related cognitive processing and control of chronic pain in patients with primary headache.

Methods

A clinical trial was conducted in 2017 - 2018 on 85 Persian language patients with one type of primary headache selected through purposive sampling in Emam Hossein Hospital in Tehran province. To measure the variables of the study, we used the Brief Pain Inventory (BPI) and Pain-related Cognitive Processing Questionnaire (PCPQ). All data were analyzed by independent t-test and chi-square and longitudinal data were analyzed using linear mixed model analysis.

Results

Statistically significant time × group interactions were found in pain intensity (P < 0.001), pain interference (P < 0.001), as well as in three cognitive processing subscales including pain focus, pain distancing, and pain openness (P < 0.001). However, the results of pain diversion were not meaningful.

Conclusions

MBCT is a potentially efficacious approach for individuals with headache pain. Regulation and correction of cognitive processing are considered as effective cognitive coping strategies in MBCT treatment.

The Role of Mindfulness in Predicting Pain Interference in Patients with Primary Headache

Background

Primary headaches are one of the most troubled chronic diseases. Headaches interfere within the various dimensions of the patient's life. Coping strategies that aim to be attention focused (e.g., mindfulness) may moderate pain-related emotional and physical interference.

Objectives

This investigation examined the relationship between mindfulness and pain intensity with physical and emotional interference and the subsequent aim was to analyze the role of mindfulness and headache severity combination in the prediction of pain-related interference.

Methods

This correlational study was conducted during years 2017 to 2018 at Imam Hossein Hospital of Tehran province. Eighty-five patients (56 females and 29 males), who had one type of primary headache were selected through purposive sampling after the diagnosis by a neurologist. The data were collected through the brief pain inventory (BPI) and the mindful attention awareness scale (MAAS). All data were analyzed using descriptive statistics. Bivariate correlation matrix and hierarchical stepwise linear regression statistics were used.

Results

The correlational analysis of the results indicated significant association between mindfulness (MAAS) and pain severity (BPI) (P < 0.01) as well as the findings of the study point to the significant relationship between mindfulness and both physical and emotional pain-related interference (P < 0.01). The results of stepwise linear regression indicated that pain severity explains only 1% of the total score in emotional pain-related interference (P = 0.003 and ΔF (1 and 83) = 9.22, ΔR² = 0.11). Adding mindfulness to the model led to a 43% increase of the explained variance (R² Change = 0.34). In physical interference, although pain severity was able to predict pain interference (P = 0.01 and ΔF (1 and 83) = 7.09, ΔR² = 0.07), a combination model justifies 10% of the interference variance that was not statistically meaningful (P = 0.08, ΔR² = 0.103).

Conclusions

This result is a further support that Mindful Awareness contributed to emotional pain-related interference prediction. This result can explain the role of attention focused and mindful awareness in primary headache pain adjustment.

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.

Clinical characteristics of nummular headache and differentiation between spontaneous and posttraumatic variant: an observational study

BACKGROUND

Head trauma has been described as a precipitating event in Nummular Headache (NH). We aimed to describe the largest NH published series and compare characteristics between idiopathic and post-traumatic cases.

METHODS

Patients attended in a Headache Unit in a tertiary hospital (January 2008-January 2018). NH diagnosed according to International Classification of Headache Disorders (ICHD) criteria. We prospectively considered clinical and epidemiological data, comparing idiopathic cases with those precipitated by a cranial trauma.

RESULTS

We included 225 patients (145 women, 80 men) with NH. Median latency between onset and diagnosis was 10 months (IQR: 5-24). Symptomatic treatment was used in 190 patients (84.4%) among which 142 (74.7%) experienced response to it. Preventive treatment was necessary in 127 patients (51.4%), among which 95 (74.8%) achieved response. 29 patients (23 women, 6 men) described a head trauma related to beginning of pain. When comparing groups with or without previous trauma, age of onset was higher among post-traumatic patients (59.9 ± 17.4 vs 48.1 ± 18 years, p: 0.001). Allodynia upon palpation was encountered more frequently in trauma triggered painful areas (53.3% vs. 32.7%, p: 0.02). No other clinical characteristics differences were observed.

CONCLUSION

Cranial trauma is not a rare trigger of NH. Patients with post-traumatic forms are older and the presence of allodynia is more frequent.

Paroxysmal pressing headache: A new short-lasting headache

INTRODUCTION

In this report we describe a series of patients with a previously undescribed headache.

METHODS

Over a 4-year period, we recruited 14 patients with a distinctive type of head pain of unknown cause that did not meet diagnostic criteria for other primary headaches.

RESULTS

Nine women and five men with a mean age of 49.6 years (standard deviation, 17.8) presented with spontaneous headache attacks lasting 2-15 minutes. In each attack, the pain was localized to a region of one side of the head. Pain location varied between episodes in 12 patients. Pain quality was pressing, and pain intensity was mild to severe. There were no accompanying symptoms. Physical examination and all ancillary tests were unremarkable. Among seven patients who tried pharmacological treatments, one responded to antidepressants, another to indomethacin and three to other nonsteroidal anti-inflammatory drugs or simple analgesics.

CONCLUSIONS

Paroxysmal pressing headache may be a new headache syndrome marked by short duration of the pain and shifting location.

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.