What are the recommended treatments for scalp numbness and headaches?

Scalp Numbness and Headache: Diagnostic Approach and Treatment

Immediate Diagnostic Considerations

Scalp numbness with headache requires urgent evaluation to rule out secondary causes, particularly if accompanied by red flag features including sudden onset, onset after age 50, focal neurological signs, or progressive worsening. 1

Red Flag Assessment

When evaluating scalp numbness with headache, immediately screen for the following warning signs that mandate urgent neuroimaging:

• Sudden onset ("thunderclap") headache - may indicate subarachnoid hemorrhage, with CT detecting 95% on day 0 but only 50% by 1 week 2
• New onset after age 50 - up to 15% of patients over 65 with new-onset headaches have serious pathology including stroke, temporal arteritis, neoplasm, or subdural hematoma 2
• Focal neurological signs or symptoms beyond the scalp numbness itself 1
• Progressive worsening or change in headache pattern 1
• Papilledema on examination 1
• Systemic symptoms including fever, weight loss, or jaw claudication (suggesting temporal arteritis) 2

Temporal Arteritis Consideration

For patients over 50 with scalp tenderness/numbness and headache, temporal arteritis must be ruled out urgently, as 60-90% of temporal arteritis patients present with headache. 2

• Obtain erythrocyte sedimentation rate (ESR) and C-reactive protein, though ESR can be normal in 10-36% of temporal arteritis cases 2
• Consider temporal artery biopsy if clinical suspicion is high, recognizing that false-negative results occur in 5-44% of cases 2
• Do not delay corticosteroid treatment while awaiting biopsy if clinical suspicion is high, as vision loss is irreversible 2

Neuroimaging Indications

When to Image

Obtain neuroimaging (MRI preferred over CT for detail) if any red flags are present or if the neurological examination is abnormal. 1, 3

• MRI is superior to CT for detailed evaluation and is necessary for imaging the posterior fossa, though more expensive and less widely available 1
• Noncontrast CT followed by lumbar puncture is the preferred approach when subarachnoid hemorrhage is suspected 1
• For patients with normal neurological examination and typical primary headache patterns without red flags, routine neuroimaging is not warranted 4

Yield of Imaging in Routine Headache

The yield of neuroimaging in patients with headache and normal neurological examination is quite low, with combined studies showing: brain tumors 0.8%, arteriovenous malformations 0.2%, aneurysms 0.1%, and strokes 1.2% 2

Treatment Based on Headache Type

If Migraine Pattern (with or without scalp symptoms)

For acute migraine attacks, start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg) as first-line therapy for mild-to-moderate attacks, escalating to triptans for moderate-to-severe attacks or NSAID failure. 5

• Combination therapy with triptan plus NSAID is superior to either agent alone for moderate-to-severe migraine 5
• Subcutaneous sumatriptan 6 mg provides the most rapid relief (within 15 minutes) for severe attacks with nausea 5
• Strictly limit all acute medications to no more than 2 days per week to prevent medication-overuse headache 5

If Tension-Type Headache Pattern

For tension-type headache, use ibuprofen 400 mg or acetaminophen 1000 mg as first-line acute treatment. 6

• For chronic tension-type headache (≥15 days per month), consider preventive therapy with amitriptyline 50-100 mg daily 6
• Monitor for anticholinergic adverse effects, especially in older patients 6

Preventive Therapy Indications

Initiate preventive therapy if headaches occur more than 2 days per week, produce disability lasting 3+ days per month, or when acute treatments are contraindicated or ineffective. 5, 7

First-line preventive options include:

• Topiramate 25-100 mg daily (start low, titrate slowly over 2-3 months) 7
• Propranolol 80-240 mg daily or timolol 20-30 mg daily 5
• Amitriptyline 30-150 mg daily for mixed migraine and tension-type headache 5

Critical Pitfalls to Avoid

• Do not dismiss scalp numbness as benign without thorough evaluation - it may represent focal neurological dysfunction warranting imaging 1
• Do not assume normal ESR rules out temporal arteritis in patients over 50 with appropriate clinical features 2
• Do not allow patients to increase acute medication frequency beyond twice weekly, as this creates medication-overuse headache 8, 5
• Do not delay imaging in patients with red flag features due to cost concerns - the consequences of missing serious pathology far outweigh imaging costs 1

When to Refer

Refer to neurology for:

• Headaches difficult to diagnose or classify 1
• Headaches that worsen or fail to respond to initial management 1
• Chronic migraine (≥15 headache days per month) 8
• Atypical features or concerning neurological findings 4