Can Hyperostosis Frontalis Interna Cause Headaches?
Yes, hyperostosis frontalis interna (HFI) can cause headaches in older adults, though it is often an incidental finding. While HFI is frequently dismissed as a benign anatomical variant, emerging evidence demonstrates that severe cases can produce significant symptomatology including treatment-resistant headaches 1.
Clinical Significance of HFI
HFI represents irregular thickening of the inner table of the frontal bone, predominantly affecting postmenopausal women with increasing prevalence in older age groups 2. The condition shows clear age and sex patterns:
- Prevalence increases with age in women, reaching 16.4% in those over 65 years 2
- Male prevalence remains stable across age groups with no significant age-related progression 2
- Overall prevalence is approximately 8.1%, with significantly higher rates in females 2
Headache Association
The relationship between HFI and headaches is documented but not universal:
- Severe cases can present with treatment-resistant headaches requiring surgical intervention, as demonstrated in a 27-year-old female with massive frontal bone overgrowth 1
- HFI may be accompanied by headache along with other neuropsychiatric symptoms including epilepsy and dementia 3
- Clinical implications range from nonspecific symptoms to severe manifestations including headache, motor aphasia, parkinsonism, and depression in advanced cases 4
Diagnostic Approach
When evaluating headaches in patients with suspected or known HFI:
- Measure metabolic parameters including serum calcium, phosphorus, creatinine, alkaline phosphatase, PTH, and 25(OH) vitamin D to exclude treatable metabolic bone diseases 5
- MRI with black bone sequence is preferred over conventional skull radiography for accurate bone structure evaluation 5
- Consider alternative diagnoses including Paget's disease (elevated ALP, age >50, mixed bone lesions), hyperparathyroidism (elevated ALP and PTH), and osteomalacia (low phosphorus, elevated ALP, low vitamin D) 5
Management of HFI-Associated Headaches
Topiramate is recommended as first-line prophylaxis, starting at 25mg and titrating weekly to 50mg twice daily 5. This represents the primary pharmacological approach for headache management in HFI patients.
Additional therapeutic options include:
- OnabotulinumtoxinA (Botox) is FDA-approved specifically for chronic migraine prophylaxis in HFI patients 5
- Non-pharmacological interventions including cognitive-behavioral therapy, relaxation training, and biofeedback are effective for headache management 5
- NSAIDs (ibuprofen or naproxen) can be used for acute pain control 6
Critical Diagnostic Pitfall
Do not dismiss HFI as merely incidental when patients present with headaches. The presence of HFI may result in severe symptomatology that could be misinterpreted and attributed to other disorders if not radiologically recognized and properly reported 1. Failure to identify HFI as a potential headache source can lead to prolonged suffering and inappropriate treatment attempts.
Special Considerations
In patients with scalp tenderness, jaw claudication, or temporal pain, evaluate for giant cell arteritis with immediate ESR, CRP, and temporal artery biopsy, as GCA can coexist with HFI 5, 3. The association between these conditions, though rare, has been documented 3.
Estrogen receptor expression on frontal dura supports the hormonal pathogenesis theory of HFI, explaining its predominance in postmenopausal women and potential for symptom development 1.