Headache Medicine, v.7, n.4, p.133-136, Oct./Nov./Dec. 2016 133

Secondary nummular headache: a literature review

Cefaleia numular secundária: Revisão de literatura

Arthur C. Holanda

, Marília A. Batista

, Raiza R. B. Oliveira

, Maria Carolina M. de Oliveira

, Carolina A. Asfora

Aída C. S. do Nascimento

, Eric C. Arraes

, Rafael G. Costa

, Marcelo M. Valença

1,3

Universidade Federal de Pernambuco, Recife, Brasil

Universidade de Pernambuco, Recife, Brasil

Serviço de Neurocirurgia, Hospital Esperança, Recife, Brasil

Holanda AC, Batista MA, Oliveira RRB, Oliveira MCM, Asfora CA, Nascimento ACS, Arraes EC, Costa RG, Valença MM.

Secondary nummular headache: a literature review. Headache Medicine. 2016;7(4):133-6

VIEW AND REVIEW

ABSTRACT

Introduction: Despite being recognized only as a primary

headache, some studies in the literature suggest the existence

of nummular headache secondary to structural lesions and

other diseases. The aim of this literature review is to compile

the cases of probable secondary nummular headache

reported in the literature. Methods: The terms "nummular

headache" and "coin-shaped headache" were searched in

five databases (MEDLINE, Scopus, SciELO, LILACS and

Cochrane Library). Only articles that described cases of

patients diagnosed with nummular headache were included.

The cases were considered as secondary when a cause for

the headache was suggested by the authors. Results: After

excluding reviews and non-related or duplicated studies, 50

articles were included. A total of 343 cases of nummular

headache were, at least, mentioned by these studies, and 30

of them were considered as secondary. Conclusion: there

are few reports of secondary nummular headache in the

literature; still, they represent a considerable percentage of

the reported cases of nummular headache. They support that

structural lesions and other diseases should be considered in

the differential diagnosis of primary nummular headache.

Keywords: Nummular headache, Headache

RESUMO

Introdução: Apesar de ser reconhecida apenas como uma

cefaleia primária, alguns estudos na literatura sugerem a

existência de cefaleia numular secundária a lesões estrutu-

rais e outras doenças. O objetivo dessa revisão de literatura

é compilar os casos de provável cefaleia numular secundá-

ria reportados na literatura. Métodos: Os termos "nummular

headache" e "coin-shaped headache" foram pesquisados em

cinco bases (MEDLINE, Scopus, SciELO, LILACS e Cochrane

Library). Apenas artigos que descrevem casos de pacientes

diagnosticados com cefaleia numular foram incluídos. Os

casos foram considerados secundários quando uma causa

para a cefaleia foi sugerida pelos autores. Resultados: Após

excluir artigos de revisão e artigos não relacionados ou du-

plicados, 50 artigos foram incluídos. Um total de 343 casos

de cefaleia numular foram, ao menos, citados por esses

estudos, e 30 deles foram considerados secundários. Con-

clusão: Existem poucos relatos de cefaleia numular secun-

dária na literatura; ainda assim, representam uma porcen-

tagem considerável dos casos reportados de cefaleia numular.

Eles apoiam a ideia de que lesões estruturais e outras doen-

ças devem ser consideradas no diagnóstico diferencial de

cefaleia numular primária.

Palavras-chave: Cefaleia numular, Cefaleia

INTRODUCTION

Nummular headache is described in the International

Classification of Headache Disorders 3

edition (beta

version) (ICDH 3-β),

(1)

as a frequently chronic pain located

in a small circumscribed area of the scalp, not caused by

structural lesions. It can be continuous or intermittent, being

sharply contoured, fixed in size and shape, round or elliptical

and between 1 and 6 cm of diameter.

(1)

Despite being recognized only as a primary headache,

some studies in the literature suggest the existence of

nummular headache secondary to structural lesions and

other diseases. In this context, the aim of this literature

review is to compile the cases of probable secondary

nummular headache reported in the literature.

134 Headache Medicine, v.7, n.4, p.133-136, Oct./Nov./Dec. 2016

HOLANDA AC, BATISTA MA, OLIVEIRA RRB, OLIVEIRA MCM, ASFORA CA, NASCIMENTO ACS, ET AL

METHODS

The terms "nummular headache" and "coin-shaped

headache" were searched in five databases (MEDLINE,

Scopus, SciELO, LILACS and Cochrane Library). The review

was performed up to 2015. Only articles that described

cases of patients diagnosed with nummular headache were

included. The cases were considered as secondary when a

cause for the headache was suggested by the authors.

RESULTS

The search in MEDLINE, Scopus, SciELO, LILACS and

Cochrane Library yielded 68, 89, one, one and no articles,

respectively. After excluding reviews and non-related or

duplicated studies, 50 articles were included. A total of 343

cases of nummular headache were, at least, mentioned by

these studies, and 30 of them were considered as secondary.

Table 1 describes all the 30 cases and their suggested

etiologies. Half of them were related to autoimmune

diseases. Other possible causes associated with the onset

of the headache were superficial masses (3 cases), tumors

in the sellar region (3 cases), head trauma (3 cases),

aneurysms (2 cases), insect bite (1 case), varicella-zoster

infection (1 case), craniosynostosis (1 case) and a

protruding bone lesion (1 case).

The distribution of characteristics (Table 2) was similar

to those of the two previous literature reviews.

(2,3)

Nummular

headache was more common in women (73.3%), being

restricted to a circular area (73.3%) in the parietal region

Table 1 - Cases of nummular headache with suggested etiologies

Study Age (sex) Site (side) Size

Quality (intensity) Suggested etiology Effective treatment

Dash, 2006 27 (M) P (L) 2.5 Burning (mod) Head trauma None

Guillem, 2007 60 (F) T (L) - - (mild) Subtentorial meningioma Surgery

Pareja, 2008 65 (F) P (R) 4.5 Stabbing (sev) Head trauma -

60 (M) P (L) 4 Pressing (mild) Insect bite -

Alvaro, 2009 67 (M) P (L) 5 Pressing (mild) Protruding lesion Nerve block

72 (F) V 4 - (mod) Post-op. (pit. adenoma) None

Guillem, 2009 52 (F) PO (R) 2.5 - Arachnoid cyst None

36 (F) PT (R) 5 Pressing (mod) Arachnoid cyst Pregabaline

Moon, 2010 77 (M) P (L) 10 - Head trauma -

Chen, 2012a 62 (F) P (L) 4 Electric (mod) VZ infection Fanciclo vir, gabapentin

Chen, 2012b 75 (F) P (R) - - Prim. SjS -

52 (F) P (B) - - Prim. SjS -

38 (F) PT (R) - - RA, APS -

48 (F) P (R) - - SS -

74 (F) P (L) - - Prim. SjS, RA, AS -

73 (F) P (L) - - APS -

64 (F) P (L) - - APS -

72 (F) P (R) - - SS -

66 (F) P (R) - - SjS -

51 (F) P (B) - - SS -

68 (F) P (R) - - SS, prim. SjS -

61 (F) P (L) - - Prim. SjS -

57 (F) P (R) - - Prim. SjS -

47 (M) P (R) - - RA -

Chui, 2013 54 (F) V 3 Electric (mod) Pit. oncocytoma Surgery

Irimia, 2013 33 (F) O (R) 3 Boring (mod) Alopecia areata Botulinum toxin A

Yin, 2013 58 (F) V 4.5 Electric (-) Post-op. (pit. prolactinoma) Gabapentin

Mesonero, 2014 41 (F) P (L) 3 Pressing (-) Craniosynostosis No treatment

Ruiz, 2014 67 (M) T (R) 4 Pressing (sev) TA fusiform aneurysm (R) Surgery

60 (M) O (R) 5 Boring (mod) OA fusiform aneurysm (R) Triptans

M - male; F - female; P - parietal; T - temporal; O - occipital; PT - Parieto-temporal; PO - Parieto-occipital; V - vertex; L - left;

R - Right; mod - moderate; sev - severe; post-op. - postoperative; pit - pituitary; VZ - Varicella-zoster; Prim. SjS - primary Sjogren

syndrome; RA - rheumatoid arthritis; APS - antiphospholipid syndrome; SS - sicca syndrome; AS - ankylosing spondylitis;

TA - temporal artery; OA - occipital artery. a - in cm, representing the wider diameter; b - treatment with the best results.

Headache Medicine, v.7, n.4, p.133-136, Oct./Nov./Dec. 2016 135

SECONDARY NUMMULAR HEADACHE: A LITERATURE REVIEW

(66.7%). It presented more frequently as a mild to moderate

(83.3%) pressing (41.7%) pain in a continuous pattern

(85.7%), with exacerbations (58.3%), sensory disturbances

(46.7%) and tenderness to palpation (56.3%).

The pain was, diminished in half of the cases in which

anticonvulsants, as gabapentin, were used, while antidepressants,

as amitriptyline, were not useful in any patient. The headache

disappeared only in two patients treated with gabapentin

(4,5)

and in the three who underwent surgical procedure.

(6-8)

DISCUSSION

The current study reviewed the cases of nummular

headache in the literature and described the information

from studies that associated this headache to other

conditions. While case reports and observational studies

have been increasing in number, only few articles have

suggested a cause for the reported cases,

(4-16)

and a

secondary entity for nummular headache is still not

recognized.

The most common characteristics of these cases were

similar to those found by Dai et al.

(2)

and Schwartz et al.,

(3)

as well as to those described in the ICDH 3-β

(1)

for primary

nummular headache. In fact, according to the ICDH 3-

(1)

diagnosis of nummular headache is made after

exclusion of structural causes. Furthermore, a correlation

between the headache and other diseases does not mean

that the former is caused by the latter, and it is also possible

that some of the cases were not related to the patient's

history nor their concurrent conditions. However, some of

the reports are highly suggestive of a causation relationship.

The three most compelling examples are described by

Guillem et al.,

(6)

Chui et al.

(7)

and López-Ruiz et al.

(8)

The

patients were diagnosed with, respectively, a subtentorial

meningioma, a pituitary oncocytoma and a fusiform

aneurysm in the right temporal artery, after presenting

nummular headache as the only or major symptom. The

headache characteristics were different between the cases,

but its location was related to the site of the pathology in

all of them. The pain disappeared rapidly after the surgery

and did not recur in the three patients.

Head trauma was suggested as the cause of nummular

headache in only three cases reported in the

literature,

(11,15,16)

while it was not considered as a probable

cause in other cases with history of trauma.

(17)

The

relationship between trauma and nummular headache is

very difficult to establish; however, of the two cases with

information available, one

(15)

had a headache starting

immediately after the event, and both

(11,15)

had the location

of pain restricted to the site of the trauma.

The difficulty in distinguishing primary from a possible

secondary nummular headache has implications regarding

its clinical assessment. As the headache is commonly mild

and the possibility of an underlying cause is not often

recognized, secondary conditions may be underdiagnosed,

at least until the presentation of other symptoms. Despite of

their rarity in the literature, secondary nummular headaches

should be considered, and imaging evaluation can be a

helpful tool for an early diagnosis.

Table 2 - Characteristics of possible secondary cases described in

the literature.

Characteristics

Gender, % (M/F, 30 cases)

Age when reported (30 cases), y

Duration of NH (22 cases), y

Prior or concurrent headache (24 cases), %

26.7/73.3

57.9 (29-77)

3 (0-22)

29.2

Side of the headache (30 cases)

Left, %

Right, %

Midline, %

Bilateral, %

43.3

6.7

Localization (30 cases)

Parietal, %

Vertex, %

Temporal, %

Occipital, %

Parieto-temporal, %

Parieto-occipital, %

66.7

6.7

3.3

Morphology (15 cases)

Mean diameter (range), cm

Circular, %

Oval, %

4.5 (2.5-10)

73.3

26.7

Pain quality (12 cases)

Pressing, %

Electric, %

Boring, %

Stabbing, %

Burning, %

41.7

16.7

8.3

Pain intensity

(12 cases)

Mild to moderate, %

Severe, %

83.3

16.7

Exacerbations (12 cases), %

Sensory disturbances (15 cases), %

Tenderness (16 cases), %

Trophic changes (14 cases), %

58.3

46.7

56.3

21.4

Temporal pattern

(14 cases)

Chronic-continuous, %

Episodic, %

85.7

14.3

Treatment responsiveness

(13 cases)

Analgesics (8 cases), %

Anticonvulsants (8 cases), %

Antidepressants (5 cases), %

Nerve block (4 cases), %

Botulinum toxin (1 case), %

Surgery (3 cases), %

Triptans (2 cases), %

12.5

100

M - male; F - female; NH - nummular headache. a - based on the visual

analogue scale; b - based on presence or absence of remissions;

c - considered when resulted in any improvement of the pain.

136 Headache Medicine, v.7, n.4, p.133-136, Oct./Nov./Dec. 2016

The described cases also provide information to the

debate regarding the pathogenesis of nummular headache.

As the patient with the pituitary oncocytoma,

(7)

two patients

developed the headache in the vertex after surgery in the

sellar region.

(5,9)

The location in the midline and the possible

referred aspect of the pain support a central mechanism

for nummular headache.

(5,9)

Meanwhile, the cases of

subtentorial meningioma(6) and arachnoid cysts,

(12)

for

example, suggest a peripheral mechanism by traction of

dural nerve branches due to expansion of such lesions.

(6,12)

It is important to emphasize that the results of the

present review should be analyzed carefully, as the cases

and studies are scarce, and some details are lacking in

many reports. These factors influenced the frequencies found

for the headache features, especially the rate of suggested

causes. One example is the high amount of autoimmune

diseases, only described by two articles.

(10,13)

Nevertheless,

the information is useful in order to provide more attention

to the existence of secondary nummular headaches.

In conclusion, there are few reports of secondary

nummular headache in the literature; still, they represent a

considerable percentage of the reported cases of nummular

headache. They support that structural lesions and other

diseases should be considered in the differential diagnosis

of primary nummular headache. Only by recognizing it as

an actual entity and by reporting new cases is that a better

understanding about its clinical characteristics can be

promoted, improving the diagnostic evaluation and the

use of complementary exams.

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Correspondênc

Arthur C. Holanda

Curso de Medicine, Universidade Federal

de Pernambuco, Recife, Brasil

Recebido: 23 de agosto de 2016

Aceito: 2 de outubro de 2016

HOLANDA AC, BATISTA MA, OLIVEIRA RRB, OLIVEIRA MCM, ASFORA CA, NASCIMENTO ACS, ET AL