Nummular Headache: A Series with Symptomatic and Primary Cases

Abstract

Nummular headache (NH) is a primary headache adopting the form of local pain in a circumscribed area of < 7 cm in diameter in the tuber parietale, albeit it may also be located in other areas of the head. Although it is chronic, it is commonly associated with exacerbations and short periods of remission. Here we report four cases. Two of them could not be considered primary: in one the pain was related to an underlying, pointed and benign lesion disclosed only by magnetic resonance imaging (case 1); the second one had persistent NH days after trans-sphenoidal surgery for a pituitary adenoma, similar to a postcraniotomy headache (case 2). The two final patients suffered from typical forms of primary NH, one associated with migraine without aura, the other with chronic tension-type headache. The response to pain-related treatments and to preventive drugs was poor in the symptomatic as well as in the primary cases. The mechanisms are not clear, and peripheral (case 1) and also central pathways (case 2) could be involved. In the end, secondary forms of NH might coexist with classical primary NH. Particular attention should be paid to tiny skull lesions and to key events preceding the pain.

A high prevalence of autoimmune indices and disorders in primary nummular headache

“…We think that there are three important reasons for underestimation, including a paucisymptomatology of autoimmune disorder at initial presentation, an incomplete survey of autoimmune indices in overall patients, and a shortage of detailed follow-up study after an initial diagnosis of NH. Nevertheless, the findings in our patients urge us to examine the primary theory of NH when autoimmune disorders are prevalent in our series and intracranial secondaries [6][7][8] have also been found in a few NH patients.…”

“…NH is proposed a form of peripheral neuralgia of the trigeminal nerve [3] which is supported by the consistency of pain pattern, focal atrophic change [4], and local sensory alteration [5] within the painful area. Although intracranial secondaries [6][7][8] and previous focal trauma [9] have been found in a few NH patients, the etiopathogenesis of NH is factually unknown. Since autoimmune disorders frequently involve the trigeminosensory nerve to produce a variety of craniofacial pain, they may therefore also provoke NH.…”

Nummular headache and pituitary lesion: A case report and literature review

“…Grosberg et al .,[11] described a patient who suffered NH shortly after sinus surgery. Alvaro et al .,[12] mentioned a woman who suffered NH a few days after trans-sphenoidal surgery for the pituitary growth hormone adenoma. The drug response and prognosis in these two patients was not further discussed.…”

Depression and anxiety are not related to nummular headache

“…NH was first described in 2002 [1] and it was subsequently included in the appendix of the 2nd edition of the International Classification of Headache Disorders [4]. Several clinical series have been published since then [5–9], but population epidemiological data are still lacking.…”