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Abstract
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.
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Affiliation(s)
- María-Luz Cuadrado
- Headache Unit, Department of Neurology, Instituto de Investigación Sanitaria San Carlos, Hospital Clínico San Carlos, Madrid, Spain.,Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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Treatment of Primary Nummular Headache: A Series of 183 Patients from the NUMITOR Study. J Clin Med 2022; 12:jcm12010122. [PMID: 36614923 PMCID: PMC9821628 DOI: 10.3390/jcm12010122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/12/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022] Open
Abstract
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.
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Zhou S, Badash I, Doherty JK. Nummular and Side-locked Headaches for the Otolaryngologist. Otolaryngol Clin North Am 2022; 55:697-706. [PMID: 35490038 DOI: 10.1016/j.otc.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Sheng Zhou
- LAC+USC Medical Center Otolaryngology Department, 1200 North State Street, Suite A2E, Los Angeles, CA 90033, USA.
| | - Ido Badash
- LAC+USC Medical Center Otolaryngology Department, 1200 North State Street, Suite A2E, Los Angeles, CA 90033, USA
| | - Joni K Doherty
- USC Caruso Department of Otolaryngology Head and Neck Surgery, 1450 San Pablo Street #5100, Los Angeles, CA 90033, USA
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García-Iglesias C, Martínez-Badillo C, García-Azorín D, Trigo-López J, Martínez-Pías E, Guerrero-Peral ÁL. SECONDARY NUMMULAR HEADACHE: A NEW CASE SERIES AND REVIEW OF THE LITERATURE. PAIN MEDICINE 2021; 22:2718-2727. [PMID: 34022054 DOI: 10.1093/pm/pnab174] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
| | | | - David García-Azorín
- Headache Unit, Neurology Department, Hospital Clínico Universitario, Valladolid, Spain
| | - Javier Trigo-López
- Headache Unit, Neurology Department, Hospital Clínico Universitario, Valladolid, Spain
| | - Enrique Martínez-Pías
- Headache Unit, Neurology Department, Hospital Clínico Universitario, Valladolid, Spain
| | - Ángel Luis Guerrero-Peral
- Headache Unit, Neurology Department, Hospital Clínico Universitario, Valladolid, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Department of Medicine, University of Valladolid, Valladolid, Spain
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Thomas DC, Heir GM, Patil AG, Soni PK. Nummular Headache - a Case Report of a Rare Entity. Curr Pain Headache Rep 2020; 24:71. [PMID: 33047184 DOI: 10.1007/s11916-020-00901-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2020] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Davis C Thomas
- Center for TMD and Orofacial Pain, Rutgers School of Dental Medicine, Newark, NJ, USA.
| | - Gary M Heir
- Center for TMD and Orofacial Pain, Rutgers School of Dental Medicine, Newark, NJ, USA
| | - Amey G Patil
- Department of Restorative Dentistry and Department of Diagnostic Sciences, Center for TMD and Orofacial Pain, Rutgers School of Dental Medicine, Newark, NJ, USA
| | - Prutha K Soni
- Center for TMD and Orofacial Pain, Rutgers School of Dental Medicine, Newark, NJ, USA
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Baldelli I, Lucia Mangialardi M, Salgarello M, Raposio E. Nummular Headache and Its Surgical Treatment. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2989. [PMID: 32802677 PMCID: PMC7413807 DOI: 10.1097/gox.0000000000002989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/26/2020] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
- Ilaria Baldelli
- From the Clinica di Chirurgia Plastica e Ricostruttiva, Ospedale Policlinico San Martino e Sezione di Chirurgia Plastica, Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate–DISC, Università degli Studi di Genova, Genova, Italy
| | - Maria Lucia Mangialardi
- Istituto di Clinica Chirurgica, Dipartimento Scienze della Salute della Donna e del Bambino, Università Cattolica del Sacro Cuore e Unità di Chirurgia Plastica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marzia Salgarello
- Istituto di Clinica Chirurgica, Dipartimento Scienze della Salute della Donna e del Bambino, Università Cattolica del Sacro Cuore e Unità di Chirurgia Plastica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Edoardo Raposio
- From the Clinica di Chirurgia Plastica e Ricostruttiva, Ospedale Policlinico San Martino e Sezione di Chirurgia Plastica, Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate–DISC, Università degli Studi di Genova, Genova, Italy
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Patel UK, Saleem S, Anwar A, Malik P, Chauhan B, Kapoor A, Arumaithurai K, Kavi T. Characteristics and treatment effectiveness of the nummular headache: a systematic review and analysis of 110 cases. BMJ Neurol Open 2020; 2:e000049. [PMID: 33681785 PMCID: PMC7871727 DOI: 10.1136/bmjno-2020-000049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 02/17/2020] [Accepted: 03/01/2020] [Indexed: 01/03/2023] Open
Abstract
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.
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Affiliation(s)
- Urvish K Patel
- Department of Neurology and Public Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sidra Saleem
- Department of Neurology, University of Toledo, Toledo, Ohio, USA
| | - Arsalan Anwar
- Department of Neurology, UH Cleveland Medical Center, Cleveland, Ohio, USA
| | - Preeti Malik
- Department of Public Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Bindi Chauhan
- Department of Public Health, Long Island University, Brooklyn, New York, USA
| | - Ashish Kapoor
- Department of Neurology, Bayonne Medical Center, Bayonne, New Jersey, USA
| | | | - Tapan Kavi
- Department of Neurology, Rowan University Cooper Medical School, Camden, New Jersey, USA
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Pellesi L, Cevoli S, Favoni V, Lupi C, Mampreso E, Negro A, Russo A, Benemei S, Guerzoni S. Nummular headache: a gender-oriented perspective on a case series from the RegistRare Network. Neurol Sci 2019; 41:583-589. [DOI: 10.1007/s10072-019-04129-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/26/2019] [Indexed: 12/16/2022]
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García-Azorín D, Trigo-López J, Sierra Á, Blanco-García L, Martínez-Pías E, Martínez B, Talavera B, Guerrero ÁL. Observational, open-label, non-randomized study on the efficacy of onabotulinumtoxinA in the treatment of nummular headache: The pre-numabot study. Cephalalgia 2019; 39:1818-1826. [DOI: 10.1177/0333102419863023] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- David García-Azorín
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Javier Trigo-López
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Álvaro Sierra
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - Enrique Martínez-Pías
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Blanca Martínez
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Blanca Talavera
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Ángel L Guerrero
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Department of Medicine, University of Valladolid, Valladolid, Spain
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Trigo J, García-Azorín D, Martinez Pias E, Sierra Á, Chavarría A, Guerrero AL. Clinical characteristics of nummular headache and differentiation between spontaneous and posttraumatic variant: an observational study. J Headache Pain 2019; 20:34. [PMID: 30961529 PMCID: PMC6734533 DOI: 10.1186/s10194-019-0981-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 03/14/2019] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Javier Trigo
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Avda. Ramón y Cajal 3, 47005 Valladolid, Spain
| | - David García-Azorín
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Avda. Ramón y Cajal 3, 47005 Valladolid, Spain
| | - Enrique Martinez Pias
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Avda. Ramón y Cajal 3, 47005 Valladolid, Spain
| | - Álvaro Sierra
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Avda. Ramón y Cajal 3, 47005 Valladolid, Spain
| | - Alba Chavarría
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Avda. Ramón y Cajal 3, 47005 Valladolid, Spain
| | - Angel Luis Guerrero
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Avda. Ramón y Cajal 3, 47005 Valladolid, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Department of Medicine, University of Valladolid, Valladolid, Spain
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Jiang L, Li M, Liu Q, Liu C, Zhou J. Nummular Headache: 2 Cases With Good Beta Blocker Responses and a Narrative Review. Headache 2019; 59:593-602. [PMID: 30869172 DOI: 10.1111/head.13503] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2019] [Indexed: 01/09/2023]
Affiliation(s)
- Li Jiang
- Department of Neurology The First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Maolin Li
- Department of Neurology The First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Qing Liu
- Department of Neurology The First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Chaoyang Liu
- Department of Neurology The First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Jiying Zhou
- Department of Neurology The First Affiliated Hospital of Chongqing Medical University Chongqing China
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Cuadrado ML, López-Ruiz P, Guerrero ÁL. Nummular headache: an update and future prospects. Expert Rev Neurother 2017; 18:9-19. [DOI: 10.1080/14737175.2018.1401925] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- María Luz Cuadrado
- Department of Neurology, Instituto de Investigación Sanitaria San Carlos (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
| | - Pedro López-Ruiz
- Department of Neurology, Hospital Universitario Quirón Madrid, Pozuelo de Alarcón, Madrid, Spain
| | - Ángel L Guerrero
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
- Department of Medicine, School of Medicine, Universidad de Valladolid (UVA), Valladolid, Spain
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Silva Rosas C, Angus-Leppan H, Lemp MB, Rozas JP, Quijada AH. Langerhans cell histiocytosis (eosinophilic granuloma) of the skull mimicking nummular headache. Report of two cases. Cephalalgia 2017; 38:794-797. [DOI: 10.1177/0333102417708772] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background Nummular headache is a rare, recently described topographic headache defined by the circumscribed coin-shaped area of pain. It is classified as a primary headache. There is debate about whether it is due to a peripheral or central disturbance, and its relationship to migraine. Case reports We report two patients with presumed nummular headache secondary to Langerhans cell histiocytosis, both with resolution of their headaches after surgical resection. Conclusion Imaging in patients with clinical features of nummular headache is recommended, as this and other cases highlight that it may be symptomatic. There are no distinguishing clinical features to separate nummular headache from secondary mimics, and treatment of the underlying cause may be curative.
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Affiliation(s)
- Carlos Silva Rosas
- Department of Neurology & Neurosurgery, Clinical Hospital of University of Chile, Santiago de Chile, Chile
| | - Heather Angus-Leppan
- Clinical Neurosciences, Royal Free London NHS Foundation Trust, London, UK
- University College London, London, UK
| | - Melchor Bruno Lemp
- Department of Neurology & Neurosurgery, Clinical Hospital of University of Chile, Santiago de Chile, Chile
| | - Juan Pablo Rozas
- Department of Neurology & Neurosurgery, Clinical Hospital of University of Chile, Santiago de Chile, Chile
| | - Alonso Humberto Quijada
- Department of Neurology & Neurosurgery, Clinical Hospital of University of Chile, Santiago de Chile, Chile
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Nelson S, Taylor LP. Headaches in brain tumor patients: primary or secondary? Headache 2016; 54:776-85. [PMID: 24697234 DOI: 10.1111/head.12326] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2014] [Indexed: 01/03/2023]
Abstract
BACKGROUND Headaches occur commonly in all patients, including those who have brain tumors. It has been argued that there is a classic "brain tumor headache type" - defined by the International Headache Society as one that is localized, progressive, worse in the morning, aggravated by coughing or bending forward, develops in temporal and often spatial relation to the neoplasm, and resolves within 7 days of surgical removal or treatment with corticosteroids. METHODS Using the search terms "headache and brain tumors," "intracranial neoplasms and headache," and "facial pain and brain tumors," we reviewed the literature from the past 20 years on brain tumor-associated headache and reflected upon the International Classification of Headache Disorders-3 (ICHD-3). In a separate, complementary paper, the proposed mechanisms of brain tumor headache are reviewed. RESULTS We discuss multiple clinical presentations of brain tumor headaches, present the ICHD-3 diagnostic criteria for each type of headache, and then apply our findings to the ICHD-3. Our primary and major finding was that brain tumor headaches can present similarly to primary headaches in those with a predisposition to headaches, suggesting that following ICHD-3 criteria could cause a clinician to overlook a headache caused by a brain tumor. We further find that some types of headaches are not explicitly discussed in the ICHD-3 and also propose that the International Headache Society formally define SMART (Stroke-like Migraine Attacks after Radiation Therapy) syndrome given the increasing amount of literature on this disorder. CONCLUSION Our literature review revealed that brain tumor headache uncommonly presents with classic brain tumor headache characteristics and often satisfies criteria for a primary headache category such as migraine or tension-type. Thus, clinicians may miss headaches due to brain tumors in following ICHD-3 criteria, and the distinction between primary and secondary headache disorders may not be so clear-cut.
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Affiliation(s)
- Sarah Nelson
- Departments of Neurology, Tufts Medical Center, Boston, MA, USA
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López-Ruiz P, Cuadrado ML, Aledo-Serrano A, Alonso-Oviés A, Porta-Etessam J, Ganado T. Superficial Artery Aneurysms Underlying Nummular Headache - 2 Cases and Proposed Diagnostic Work-Up. Headache 2014; 54:1217-21. [DOI: 10.1111/head.12398] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Pedro López-Ruiz
- Department of Neurology; Hospital Clínico San Carlos, Universidad Complutense; Madrid Spain
| | - María-Luz Cuadrado
- Department of Neurology; Hospital Clínico San Carlos, Universidad Complutense; Madrid Spain
| | - Angel Aledo-Serrano
- Department of Neurology; Hospital Clínico San Carlos, Universidad Complutense; Madrid Spain
| | - Almudena Alonso-Oviés
- Department of Oral and Maxillofacial Surgery; Hospital Clínico San Carlos, Universidad Complutense; Madrid Spain
| | - Jesús Porta-Etessam
- Department of Neurology; Hospital Clínico San Carlos, Universidad Complutense; Madrid Spain
| | - Tomás Ganado
- Department of Radiology; Hospital Clínico San Carlos, Universidad Complutense; Madrid Spain
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Iwanowski P, Kozubski W, Losy J. Nummular headache in a patient with ipsilateral occipital neuralgia—A case report. Neurol Neurochir Pol 2014; 48:141-3. [DOI: 10.1016/j.pjnns.2013.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 09/02/2013] [Indexed: 11/29/2022]
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López-Mesonero L, Porta-Etessam J, Ordás CM, Muñiz-Castrillo S, Cuadrado ML. Nummular headache in a patient with craniosynostosis: one more evidence for a peripheral mechanism. PAIN MEDICINE 2013; 15:714-6. [PMID: 24341452 DOI: 10.1111/pme.12324] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Luis López-Mesonero
- Department of Neurology, Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain
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Nummular headache after trans-sphenoidal surgery: a referred pain-based headache syndrome. Neurol Neurochir Pol 2013; 47:398-401. [PMID: 23986431 DOI: 10.5114/ninp.2013.36764] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Nummular headache (NH) is a newly categorized primary headache characterized by a consistent location, shape and size of painful area in each attack. The etiopathogenesis is entirely unknown. Currently, the peripheral theory of epicranial neuralgia is accepted more widely than the central theory but it cannot fully explain the clinical picture. We report a patient who suffered from a relapsing and remitting course of NH at the high parietal area and vertex shortly after resection for pituitary prolactinoma via a trans-sphenoidal approach. There was no focal trophic change or paresthesia but a mild allodynia in the painful area. The patient did not exhibit trigeminal sensory disorder or cranial trauma thoroughly. The pain responded well to gabapentin. Therefore, physicians should be aware of postoperative NH, which is amenable to treatment. The findings in our patient support a dual mechanism of NH and suggest that central NH is a form of referred pain.
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Chui C, Chen WH, Yin HL. Nummular headache and pituitary lesion: A case report and literature review. Ann Indian Acad Neurol 2013; 16:226-8. [PMID: 23956570 PMCID: PMC3724080 DOI: 10.4103/0972-2327.112475] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 02/19/2013] [Accepted: 02/26/2013] [Indexed: 11/21/2022] Open
Abstract
Nummular headache (NH) is a newly categorized headache disorder characterized by a consistent clinicographics in each attack. Currently, it is considered as a primary headache disorder due to epicranial neuralgia but the pathomechanism is still unknown. We report a woman, whose recurrent NH subsided after trans-sphenoidal surgery for her pituitary oncocytoma. The recovery of NH in this patient encourages the central mechanism for NH occurrence. After a review of literature concerning, NH and intracranial secondaries we propose that central NH is a referral pain from pain-sensitive structures, such as meninges, superimposing by pre-existing lower pain threshold or pain modulation.
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Affiliation(s)
- Chi Chui
- Department of Neurosurgery, Paochien Hospital, Pingtung, Taiwan
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22
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Ulivi M, Baldacci F, Vedovello M, Vergallo A, Borelli P, Nuti A, Bonuccelli U. Localized Calcific Hematoma of the Scalp Presenting as a Nummular-Like Headache. A Case Report. Headache 2013; 54:370-2. [PMID: 23676110 DOI: 10.1111/head.12131] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Martina Ulivi
- Department of Clinical and Experimental Medicine, Neurology Unit; University of Pisa; Pisa Italy
| | - Filippo Baldacci
- Department of Clinical and Experimental Medicine, Neurology Unit; University of Pisa; Pisa Italy
| | | | - Andrea Vergallo
- Department of Clinical and Experimental Medicine, Neurology Unit; University of Pisa; Pisa Italy
| | - Paolo Borelli
- Neurology Unit; Hospital of Viareggio; Viareggio Italy
| | - Angelo Nuti
- Neurology Unit; Hospital of Viareggio; Viareggio Italy
| | - Ubaldo Bonuccelli
- Department of Clinical and Experimental Medicine, Neurology Unit; University of Pisa; Pisa Italy
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Dai W, Yu S, Liang J, Zhang M. Nummular headache: Peripheral or central? One case with reappearance of nummular headache after focal scalp was removed, and literature review. Cephalalgia 2013; 33:390-7. [PMID: 23378434 DOI: 10.1177/0333102412474504] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Wei Dai
- Department of Neurology, Chinese PLA General Hospital, People’s Republic of China
| | - Shengyuan Yu
- Department of Neurology, Chinese PLA General Hospital, People’s Republic of China
| | - Jingyao Liang
- Department of Neurology, Chinese PLA General Hospital, People’s Republic of China
| | - Mingjie Zhang
- Department of Neurology, Chinese PLA General Hospital, People’s Republic of China
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Affiliation(s)
- Luiz P. Queiroz
- Department of Neurology; Universidade Federal de Santa Catarina; Florianópolis Brazil
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26
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A high prevalence of autoimmune indices and disorders in primary nummular headache. J Neurol Sci 2012; 320:127-30. [DOI: 10.1016/j.jns.2012.07.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Accepted: 07/11/2012] [Indexed: 11/19/2022]
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Guerrero ÁL, Cortijo E, Herrero-Velázquez S, Mulero P, Miranda S, Peñas ML, Pedraza MI, Fernández R. Nummular headache with and without exacerbations: Comparative characteristics in a series of 72 patients*. Cephalalgia 2012; 32:649-53. [DOI: 10.1177/0333102412447537] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Ángel L Guerrero
- Neurology Department, Hospital Clínico Universitario, Valladolid, Spain
| | - Elisa Cortijo
- Neurology Department, Hospital Clínico Universitario, Valladolid, Spain
| | | | - Patricia Mulero
- Neurology Department, Hospital Clínico Universitario, Valladolid, Spain
| | - Sara Miranda
- Neurology Department, Hospital Clínico Universitario, Valladolid, Spain
| | - María Luz Peñas
- Neurology Department, Hospital Clínico Universitario, Valladolid, Spain
| | | | - Rosa Fernández
- Neurology Department, Hospital Clínico Universitario, Valladolid, Spain
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Guerrero ÁL, Cuadrado ML, García-García ME, Cortijo E, Herrero-Velázquez S, Rodríguez O, Mulero P, Porta-Etessam J. Bifocal Nummular Headache: A Series of 6 New Cases. Headache 2011; 51:1161-6. [DOI: 10.1111/j.1526-4610.2011.01940.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Cuadrado ML, Valle B, Fernández-de-las-Peñas C, Madeleine P, Barriga FJ, Arias JA, Arendt-Nielsen L, Pareja JA. Pressure pain sensitivity of the scalp in patients with nummular headache: a cartographic study. Cephalalgia 2011; 30:200-6. [PMID: 19489884 DOI: 10.1111/j.1468-2982.2009.01895.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- M L Cuadrado
- Department of Neurology, Hospital Clínico San Carlos and Universidad Complutense, Madrid, Spain.
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31
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Porta-Etessam J, Lapeña T, Cuadrado ML, Guerrero A, Parejo B. Multifocal Nummular Headache With Trophic Changes. Headache 2010; 50:1612-3. [DOI: 10.1111/j.1526-4610.2010.01773.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Dabscheck G, Ian Andrews P. Nummular headache associated with focal hair heterochromia in a child. Cephalalgia 2010; 30:1403-5. [DOI: 10.1177/0333102410368439] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Nummular headache (NH) is a recently described headache syndrome where continuous or intermittent pain is localised to a coin-shaped region of the skull. NH can be a primary headache disorder or secondary to intracranial or extracranial pathology. We report a four-year-old boy who presented with nummular headache co-localised with a patch of discoloured hair and propose a common aetiology.
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Abstract
Introduction: Nummular headache is a rare primary headache disorder described by a focal circumscribed area of pain (2–6 cm in diameter). Literature on this disorder is sparse. Patients and methods: Here, we describe a case series of 16 patients (6 men, 10 women) seen at the Mayo Clinic. Results: Mean age of onset was 50 years (range, 19–79 years) and mean duration of headache was 7.9 years (range, 0.33–40 years). Location of headache varied and was found to be an average of 3.9 cm in diameter (range, 2–10 cm). Headache was episodic (<15 days/month) in four patients and chronic (>15 days/month) in 12 patients. Attention was paid to therapeutic interventions. Resolution was seen in 38% of patients. Migraine was present in the history of 56% of patients and medication overuse headache was found in 25%. Conclusions: Our series results support previous findings. In our population, no specific therapy was identified to be effective in more than one patient.
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Affiliation(s)
- Justin Moon
- Denver Neurological Clinic, Denver, Colorado, USA
| | - Kamran Ahmed
- Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Ivan Garza
- Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Guerrero AL, Cuadrado ML, Porta-Etessam J, García-Ramos R, Gómez-Vicente L, Herrero S, Peñas ML, Fernández R. Epicrania fugax: ten new cases and therapeutic results. Headache 2010; 50:451-8. [PMID: 20100299 DOI: 10.1111/j.1526-4610.2009.01607.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Angel L Guerrero
- Neurology Department, Hospital Clínico Universitario, Valladolid, Spain
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Depression and anxiety are not related to nummular headache. J Headache Pain 2009; 10:441-5. [PMID: 19820896 PMCID: PMC3476210 DOI: 10.1007/s10194-009-0161-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2009] [Accepted: 09/20/2009] [Indexed: 11/21/2022] Open
Abstract
Nummular headache (NH) is a clinical picture characterized by head pain that is exclusively felt in a round, elliptical, or oval area of the head. Although there is evidence supporting an organic origin for NH, some authors question this origin, hypothesizing a potential role for psychological factors. Our aims were to investigate the differences in anxiety and depression between NH patients and healthy controls, and to analyse if these conditions were related to pain parameters in NH patients. The Beck depression inventory (BDI-II) and the trait anxiety scale from state-trait anxiety inventory (STAI) were administered to 26 patients with NH and 34 comparable matched controls. No significant interactions between group (NH patients, controls) in either depression (U = 391; p = 0.443) or anxiety levels (U = 336; p = 0.113) were found. Both groups showed similar scores in the BDI-II (patients: 3.9 ± 2.9; controls: 3.46 ± 3.15) and STAI (patients: 17.23 ± 10.3; controls: 13.5 ± 7.9). Moreover, neither depression nor anxiety showed association with mean pain intensity, pain intensity in exacerbations, size of pain area, or pain frequency. Our study demonstrated that self-reported depression and anxiety were not related to the presence of NH. Further, longitudinal studies are still needed to elucidate the role of mood state in the course of NH.
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Affiliation(s)
- MS Robbins
- Montefiore Headache Center, The Saul R. Korey Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - BM Grosberg
- Montefiore Headache Center, The Saul R. Korey Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
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