What is the treatment for nummular headache?

Treatment of Nummular Headache

For nummular headache, initiate treatment with gabapentin as first-line therapy, with NSAIDs and botulinum toxin type A as highly effective alternatives, particularly when gabapentin fails or is not tolerated. 1, 2

First-Line Treatment Options

• Gabapentin demonstrates the highest response rate (67.7%) among oral medications and should be considered the primary pharmacologic intervention for nummular headache 1

• NSAIDs show a 65.6% response rate and represent an excellent alternative first-line option, particularly for patients who prefer to avoid neuromodulating agents 1

• Tricyclic antidepressants (such as amitriptyline) have a 44.4% response rate and can be considered when gabapentin or NSAIDs are ineffective or contraindicated 1

Second-Line Treatment: Botulinum Toxin Type A

• Botulinum toxin type A (BoNT-A) achieves a 100% response rate in reported cases and should be strongly considered for patients with intractable nummular headache who fail oral medications 1, 2

• The typical injection protocol involves 25 units of BoNT-A divided among 10 injection sites within and around the circumscribed painful area 2

• Symptom reduction typically begins 6-10 days following injection, with effects lasting approximately 14 weeks, requiring repeat injections for sustained benefit 2

• BoNT-A is particularly effective for patients experiencing allodynia, tenderness, and paresthesias in the affected area 2

Treatment Algorithm

1. Initial approach: Start with gabapentin or NSAIDs based on patient preference and comorbidities 1

2. If inadequate response after 4-6 weeks: Switch to the alternative first-line agent (gabapentin if NSAIDs were tried first, or vice versa) 1

3. If both first-line agents fail: Consider tricyclic antidepressants 1

4. For refractory cases: Proceed to botulinum toxin type A injections, which have demonstrated efficacy even when NSAIDs, gabapentin, and local anesthetics have failed 2

5. For mild cases: Simple reassurance may be sufficient, as many patients experience minimal disability and treatment may not be necessary 3

Important Clinical Considerations

• Early diagnosis is associated with better outcomes: Patients diagnosed within one year of symptom onset are more likely to achieve complete resolution compared to those with delayed diagnosis (median time to diagnosis is 18 months) 1

• Female patients and younger age at onset predict better treatment response: These demographic factors are associated with higher rates of complete resolution 1

• The pain typically affects a circumscribed round, oval, or elliptical area measuring 2-6 cm in diameter, most commonly in the parietal region 4, 3

• Sensory disturbances including paresthesias, allodynia, and dysesthesias frequently accompany the pain and should be specifically addressed during treatment 4, 3

Critical Pitfalls to Avoid

• Do not mistake nummular headache for secondary causes: Rule out local structural pathology before diagnosing primary nummular headache, as the focal nature can mimic secondary processes 3

• Recognize that nummular headache can coexist with other primary headaches (such as migraine or tension-type headache) but follows an independent course requiring separate treatment 3

• Avoid premature discontinuation of treatment: Many patients experience fluctuating symptoms with pseudoremissions where pain becomes very mild or presents only as discomfort, which should not be mistaken for treatment failure 3

• The affected area remains fixed in location, shape, and size over time—any change in these characteristics should prompt reconsideration of the diagnosis 3