Characteristics and treatment effectiveness of the nummular headache: a systematic review and analysis of 110 cases

Abstract

Background/objectiveNummular 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.MethodsWe 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.ResultsWe 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%).ConclusionYounger patients, female sex and early diagnosis were associated with complete resolution. NSAIDs, gabapentin and BoNT-A were most commonly used medications, with significant RRs.

Nummular headache in children: A case series and systematic literature review

“…Gabapentin has been shown to be most frequently used and can be effective in up to two-thirds of patients with NH. 15 Many of our cases reported resolution or improvement after treatment for comorbid migraine and medication overuse headache with other anticonvulsants along with lifestyle modifications and vitamin repletion when necessary. Of note, we supplement vitamins based on documented deficiencies and not exclusively as primary prevention therapy.…”

Nummular headache responsive to anti‐calcitonin gene‐related peptide monoclonal antibodies in a patient with migraine

“…NH is a primary headache characterized by continuous or intermittent pain in a circumscribed area, usually 1–6 cm in diameter 1 . In addition to analgesics and NSAIDs, gabapentin and BoNTA injections are the most recommended treatments of NH, but to date there are no standardized treatment guidelines 10,11 . To our knowledge, this is the first reported case with poor response to the aforementioned treatments and full response to antibodies against CGRP, specifically galcanezumab.…”

“…3,4 BoNTA administration is followed by an optimal response in some patients with NH. 7,11 BoNTA acts directly on superficial sensory fibers, presumably C nerve fibers, by blocking the release of neurotransmitters | 1065 HEADACHE and neuropeptides in neurogenic inflammation and pain, including CGRP. 7,13 Our patient's NH showed little improvement with BoNTA.…”

“…The pathogenesis of NH is still unclear, but there is some evidence to support an epicranial origin, localized in the various layers of the scalp or skull, or in adjacent meningeal structures 3,4 . BoNTA administration is followed by an optimal response in some patients with NH 7,11 . BoNTA acts directly on superficial sensory fibers, presumably C nerve fibers, by blocking the release of neurotransmitters and neuropeptides involved in neurogenic inflammation and pain, including CGRP 7,13 .…”

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

“…The most frequently employed preventive drugs are gabapentin, lamotrigine and onabotulinumtoxinA (10,26,27). Both tolerability and effectiveness favour onabotulinumtoxinA (4,18,27,28). In one study, most of the treated patients experienced at least a partial response, and more than half had an optimal response (4).…”