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.

Nerve block for the treatment of headaches and cranial neuralgias - a practical approach

BACKGROUND

Several studies have presented evidence that blocking peripheral nerves is effective for the treatment of some headaches and cranial neuralgias, resulting in reduction of the frequency, intensity, and duration of pain.

OBJECTIVES

In this article we describe the role of nerve block in the treatment of headaches and cranial neuralgias, and the experience of a tertiary headache center regarding this issue. We also report the anatomical landmarks, techniques, materials used, contraindications, and side effects of peripheral nerve block, as well as the mechanisms of action of lidocaine and dexamethasone.

CONCLUSIONS

The nerve block can be used in primary (migraine, cluster headache, and nummular headache) and secondary headaches (cervicogenic headache and headache attributed to craniotomy), as well in cranial neuralgias (trigeminal neuropathies, glossopharyngeal and occipital neuralgias). In some of them this procedure is necessary for both diagnosis and treatment, while in others it is an adjuvant treatment. The block of the greater occipital nerve with an anesthetic and corticosteroid compound has proved to be effective in the treatment of cluster headache. Regarding the treatment of other headaches and cranial neuralgias, controlled studies are still necessary to clarify the real role of peripheral nerve block.

Botulinum toxin type A for the treatment of nummular headache: four case studies

OBJECTIVE

We assessed the efficacy and safety of botulinum toxin type A (BoNTA; BOTOX): Allergan, Inc., Irvine, CA, USA) in patients with nummular headache who did not respond to other treatments including nonsteroidal anti-inflammatory drugs (NSAIDs), local anesthetics, and/or gabapentin.

BACKGROUND

Nummular headache is characterized by circumscribed round or elliptical areas of fluctuating mild-to-moderate head pain in a chronic or remitting pattern. It is a relatively rare primary headache disorder that responds poorly to adequate treatment trials with local anesthetic, migraine, or neuropathic pain agents or NSAIDs.

METHODS

Four patients aged 35-58 years with intractable nummular headaches were given 25 units of BoNTA divided among 10 injection sites in and around the circumscribed affected areas of pain, paresthesia, and allodynia. All patients had 2 sets of injections approximately 14 weeks apart.

RESULTS

All patients met the International Headache Society criteria for nummular headache (International Classification of Headache Disorders, A13.7.1). Patients were female; mean age of onset was 42 years. Average disease duration prior to BoNTA treatment was 3.75 years. One patient reported concurrent episodic migraine and another reported concurrent tension-type headache. Patients reported round-shaped (n = 2; 6 and 3 cm in diameter), oval (n = 1; 4 x 2 cm), and elliptical (n = 1; 6 cm in length) areas of pain. Painful symptoms were reported in the right parietal convexity (n = 2) and the posterior frontal, unilaterally (n = 2). All patients experienced spontaneous or stimuli-triggered exacerbations and variable combinations of sensory disturbances, including allodynia, tenderness, and paresthesia. The temporal pattern was continuous in 3 patients and intermittent in one. Both the size and shape of the pain remained unchanged in all patients since the onset of nummular headache symptoms. Six to 10 days following BoNTA treatment, all patients experienced a reduction in nummular headache symptoms, which lasted approximately 14 weeks on average. Repeat injections gave the same degree of improvement. No treatment-related adverse events were reported.

CONCLUSIONS

BoNTA appears to be a well-tolerated effective treatment for intractable, persistent nummular headache in patients with an inadequate response to other treatments including NSAIDs, gabapentin, or local anesthetics.

Nummular headache: a prospective series of 14 new cases

OBJECTIVE

To study the clinical features of nummular headache (NH) and get an approach to its epidemiology.

BACKGROUND

NH has been recently described as a primary disorder characterized by head pain exclusively felt in a small rounded area typically 2-6 cm in diameter.

METHODS

Through a 1-year period we have studied all patients referred to our neurologic clinic because of head pain exclusively felt in a small-circumscribed area, and not attributed to another disorder. All the patients had normal neurological, analytical, and neuroimaging examinations. All the patients belonged within the same regional care system comprising 220,000 inhabitants.

RESULTS

A total of 11 females and 3 males were studied. Based in our hospital series, the incidence was 6.4/100,000/year. The mean age at the onset was 38 years (range: 13-72). Only three patients had another concurrent headache: migraine (n = 2), and trigeminal neuralgia (n = 1) which proved to have an independent course. All the patients reported head pain exclusively felt in either a rounded (n = 12) of 1-6 cm diameter, or an oval area (n = 2) of 5 x 3 cm, and 2 x 3 cm, respectively. Both size and shape of the painful area remained constant since the onset of symptoms. The location of the symptomatic area was mostly parietal (n = 7) or temporal (n = 5), but also frontal (n = 1) and in occiput (n = 1). The background pain was mostly mild-to-moderate, but also moderate-to-severe pain was reported. Exacerbations-either spontaneous or precipitated by combing hair or touching the symptomatic area-were reported by 8 patients. The temporal pattern was chronic-continuous (n = 7) and episodic (n = 7). Ten patients reported a variable combination of sensory disturbance (tenderness, hypoesthesia, hyperalgesia, and allodynia) in the symptomatic area. There were no autonomic accompaniments. Treatment was generally not necessary. When needed, standard oral doses of paracetamol usually sufficed.

CONCLUSIONS

NH emerges as a clear-cut clinical picture. It is a noninfrequent primary headache. The particular topography suggests the pain has a probable epicranial source conveyed by, or originated in, one/a few terminal branch(es) of the cutaneous nerves of the scalp.