What are the causes of scalp pain?

Common Causes of Scalp Pain

Scalp pain can result from various conditions including infectious, inflammatory, neurological, and vascular disorders, with proper diagnosis requiring careful evaluation of symptoms and clinical presentation.

Infectious Causes

• Tinea capitis (fungal infection) can present with painful inflammatory variants such as kerion, characterized by a painful, boggy, inflammatory mass with associated alopecia, pustules, and regional lymphadenopathy 1
• Impetigo or bacterial superinfection of the scalp can cause pain, particularly when it complicates other scalp conditions like tinea capitis 2
• Favus, a chronic inflammatory tinea capitis typically caused by T. schoenleinii, can present with yellow crusted cup-shaped lesions around follicular openings and may cause discomfort 1

Inflammatory Conditions

• Psoriasis of the scalp can cause pain, particularly during treatment with certain modalities like photodynamic therapy 1
• Alopecia areata, while typically not painful itself, can be associated with other autoimmune conditions that might cause scalp discomfort 1
• Temporomandibular disorders (TMD) can refer pain to the scalp area, affecting 5-12% of the population with peak age of 20-40 years 1

Neurological Causes

• Scalp dysesthesia presents as abnormal sensations (burning/itching) in the absence of cutaneous disease, common in geriatric populations, women, patients with diabetes, and those with psychiatric history 3
• Cervical spine disease can cause referred pain to the scalp through neurogenic pathways 3
• Trigeminal trophic syndrome and other neuropathic conditions can manifest as scalp pain 3

Vascular Causes

• Giant cell arteritis should be suspected in elderly patients presenting with scalp tenderness, jaw claudication, and pain, requiring immediate evaluation with erythrocyte sedimentation rate, C-reactive protein, and possibly temporal artery biopsy 1
• Migraine can be associated with pressure-painful scalp arteries, with studies showing that 80% of migraineurs report one or more painful arteries to pressure even between attacks 4
• Maxillary sinusitis can refer pain to the scalp region, particularly when associated with dental infections or procedures 1

Other Causes

• Spontaneous intracranial hypotension can present with orthostatic headache that may involve the scalp, worsening within 2 hours of becoming upright and improving after lying flat 1
• Post-COVID-19 syndrome has been reported to cause scalp dysesthesias in some patients 3
• Salivary gland disorders, particularly stones in the submandibular gland, can cause referred pain to the scalp area 1

Diagnostic Approach

• For suspected infectious causes, appropriate samples (scalp scrapings, hair pluck, brush samples) should be collected for microscopy and culture 2
• For suspected giant cell arteritis, immediate blood tests (ESR, CRP) and consideration of temporal artery biopsy are essential 1
• For neurological causes, detailed history of associated symptoms (facial weakness, motor weakness, vision changes) and appropriate neuroimaging may be necessary 1
• For vascular causes like migraine, examination of pressure points on scalp arteries (occipital, frontal branch, and temporal) may help with diagnosis 4

Treatment Considerations

• Treatment should be directed at the underlying cause, such as antifungals for tinea capitis, antibiotics for bacterial infections, or steroids for inflammatory conditions 2
• For giant cell arteritis, immediate consultation with a neuro-ophthalmologist and initiation of treatment is crucial 1
• For neuropathic causes, treatments targeting nerve pain may be necessary 3
• For TMD-related scalp pain, approaches may include education, intraoral appliances, cognitive behavior therapy, and physiotherapy 1

Remember that scalp pain often requires a thorough evaluation to determine the underlying cause before appropriate treatment can be initiated.