What are the treatment options for paresthesia at the back of the scalp?

Treatment of Back of Scalp Tension Paresthesia

For back of scalp tension paresthesia, initiate a trial of low-dose gabapentin or pregabalin as first-line pharmacologic therapy, combined with cervical spine range-of-motion exercises and pericranial muscle stretches performed twice daily. 1, 2, 3

Initial Diagnostic Considerations

Before initiating treatment, you must exclude serious underlying pathology:

• Assess for temporal tenderness, jaw claudication, or scalp pain to rule out giant cell arteritis, which requires immediate ESR, CRP, and temporal artery biopsy if positive 4
• Obtain cervical spine imaging (MRI or CT) as 14 of 15 patients with scalp dysesthesia demonstrate cervical spine disease, most commonly degenerative disk disease at C5-C6 2
• Consider brain MRI with and without contrast if there are associated neurological symptoms, new-onset presentation, or concern for structural lesions 5

The evidence strongly links scalp dysesthesia to cervical spine pathology, with chronic muscle tension on pericranial muscles and scalp aponeurosis secondary to underlying cervical spine disease being the proposed mechanism 2.

First-Line Treatment Algorithm

Non-Pharmacologic Therapy (Initiate Immediately)

• Prescribe a structured exercise protocol consisting of cervical spine range-of-motion exercises, gentle mobilization, and pericranial muscle stretches performed twice daily for at least 4 weeks 3
• In a pilot study, 10 of 16 patients experienced satisfactory symptom reduction, with 4 achieving complete resolution using this approach alone 3
• This intervention is low-risk, non-invasive, and addresses the underlying cervical spine dysfunction 3

Pharmacologic Therapy

Primary options:

• Oral gabapentin or pregabalin at low doses, as 4 of 7 followed patients with scalp dysesthesia improved with gabapentin 2
• Low-dose oral pregabalin demonstrated benefit in a 2019 case series of scalp dysesthesia patients 1
• Low-dose tricyclic antidepressants (doxepin 10-25 mg or amitriptyline 10-25 mg at bedtime), which resulted in improvement or complete resolution in 8 of 11 patients with scalp dysesthesia 6

Adjunctive topical therapy:

• Topical compound of amitriptyline, lidocaine, and ketamine provided benefit in recent case series 1
• Oral antihistamines and topical corticosteroids alone are insufficient but add value when combined with analgesic agents 1

Treatment Sequencing

1. Start with combined approach: Initiate cervical exercises plus low-dose gabapentin (300 mg daily, titrate to 300 mg three times daily) or pregabalin (75 mg daily, titrate to 150 mg daily) 1, 2, 3

2. If inadequate response after 4 weeks: Switch to or add low-dose tricyclic antidepressant (amitriptyline 10-25 mg at bedtime) 6

3. Consider topical analgesic compound as adjunctive therapy if oral medications provide partial but insufficient relief 1

Critical Clinical Pitfalls

• Do not dismiss as "just tension headache" without cervical spine imaging, as the vast majority of scalp dysesthesia cases have demonstrable cervical pathology 2
• Do not rely on topical corticosteroids or antihistamines alone, as these are ineffective as monotherapy for scalp dysesthesia 1
• In elderly patients, always screen for giant cell arteritis with specific questions about temporal tenderness, jaw claudication, and scalp pain before attributing symptoms to benign dysesthesia 4
• Recognize psychiatric comorbidity is common (5 of 11 patients in one series had diagnosed psychiatric disorders), but this does not negate the need to address underlying cervical spine pathology 6

Follow-Up and Monitoring

• Reassess at 4 weeks to evaluate response to exercise protocol and initial pharmacologic therapy 3
• If no improvement or worsening symptoms, consider referral to neurology for comprehensive evaluation of cervical spine disease and alternative neuropathic pain management 2
• Monitor for medication side effects, particularly sedation with gabapentinoids and tricyclic antidepressants 1, 6