Although rare, Nummular Headache causes moderate to severe pain, limited to one or more well-defined 1-6 cm round or elliptical areas on the scalp. The pain of Nummular Headache is nearly constant, although patients also report periodic spikes of intense pain in the affected locations. There are no migraine-like or autonomic symptoms, only constant or near-constant pain in a small, well-defined location or locations. These painful areas may be tender to the touch, numb, or have a tingling sensation. Nummular headache occurs in the absence of skin lesions.
Because it is rare, there are no established recommendations for treatment. Even more so than Migraine, trial and error is often necessary to find relief. Here are just a few examples.
- In the March 2010 issue of Cephalalgia, a group of doctors reported using Indomethacin to successfully treat a patient with Nummular headache. Previous treatments with simple analgesics, amitriptyline, gabapentin, and dexamethasone had been unsuccessful. When a 50 mg intramuscular injection of indomethacin resulted in temporary pain relief, the patient was prescribed 25 mg of indomethacin twice daily for 2 months. At the end of that 2 months, treatment was discontinued with total remission.
- Then in August 2011, another group of doctors reported positive treatment outcomes using Neurotropin® (NTP). NTP is used in Japan and China for the treatment of chronic pain. In this case, the affected patient was treated with 16 units per day for 2 months with complete remission. In their report, the physicians expressed hope that an ongoing trial of NTP by the US National Institutes of Health would yield positive results. Unfortunately, that trial was terminated early due to the small number of participants. The preliminary results were deemed inconclusive due to a small sample size.
- In 2015, a case study of a patient with multi-focal Nummular Headache reported remission following treatment with Gabapentin. This study also use Pressure pain Threshold testing to map out the exact location of painful areas. The results from this testing confirmed that the pain is, indeed, confined to specific round or elliptical 1-6 cm areas.
The International Classification of Headache Disorders, 3rd Edition outlines the diagnostic criteria for Nummular Headache.
Pain of highly variable duration, but often chronic, in a small circumscribed area of the scalp and in the absence of any underlying structural lesion.
- Continuous or intermittent head pain fulfilling criterion B
- Felt exclusively in an area of the scalp, with all of the following four characteristics:
- fixed in size and shape
- round or elliptical
- 1-6 cm in diameter
- Not better accounted for by another ICHD-3 diagnosis.
Other causes, in particular structural and dermatologic lesions, have been excluded by history, physical examination and appropriate investigations.
The painful area may be localized in any part of the scalp, but is usually in the parietal region. Rarely, 4.8 Nummular headache is bi- or multifocal, each symptomatic area retaining all the characteristics of nummular headache.
Pain intensity is generally mild to moderate, but occasionally severe. Superimposed on the background pain, spontaneous or triggered exacerbations may occur.
Duration is highly variable: in up to 75% of published cases, the disorder has been chronic (present for longer than 3 months), but cases have also been described with durations of seconds, minutes, hours or days.
The affected area commonly shows variable combinations of hypaesthesia, dysaesthesia, paraesthesia, allodynia and/or tenderness.
- Baldacci F, Nuti A, Lucetti C, et al (March 12, 2010), Letter to the Editor: Nummular headache dramatically responsive to indomethacin. Cephalalgia. September 2010, 30(9) 1151-1152, doi: 10.1177/0333102410361539
- International Headache Society (IHS) (2018). 4.8 Nummular Headache (n.d.). Retrieved April 28, 2018, from https://www.ichd-3.org/other-primary-headache-disorders/4-8-nummular-headache/
- National Institutes of Health, Neurotropin to Treat Chronic Neuropathic Pain. (2013, June 4). ClinicalTrials.gov, June 4, 2013. Retrieved September 23, 2016, from https://clinicaltrials.gov/ct2/show/results/NCT00006289?sect=X01256#all
- Rodríguez C, Herrero-Velázquez S, Ruiz M, et al. Pressure pain sensitivity map of multifocal nummular headache: case report. The Journal of Headache and Pain (2015) 16:38, doi: 10.1189/s10194-015-0523-7
- Yamazaki Y, Kobatake K. (21 August 2011). Letter to the Editor: Successful treatment of nummular headache with Neurotropin®. The Journal of Headache and Pain (9 September 2011), 12:661-662, doi: 10.1007/s10194-011-0382-9
© Copyright 2018 Tammy Rome. All rights reserved.
Medical Review by: David Watson, MD