Nummular headache responsive to anti‐calcitonin gene‐related peptide monoclonal antibodies in a patient with migraine

Abstract

Background Nummular headache (NH) is defined by the presence of localized pain circumscribed to a round or elliptical area of the scalp, with a well‐defined contour and a diameter of 1–6 cm. Although some evidence supports a peripheral mechanism, its etiopathogenesis remains unclear. Case We report the case of a 64‐year‐old man with high‐frequency episodic migraine who has used topiramate, beta‐blockers, flunarizine, and amitriptyline without effect. In the last 8 years he also had continuous pain in an oval area of the scalp, consistent with NH. Triptans were ineffective for this new pain, and preventive therapy with gabapentin and onabotulinumtoxinA in the painful area had no effect. NH remitted when the patient received monthly treatment with subcutaneous galcanezumab for his migraine. Conclusions Monoclonal antibodies against calcitonin gene‐related peptide (CGRP), in particular galcanezumab, might be an effective therapy in some patients with NH. CGRP may have a role in the etiopathogenesis of this headache, which warrants further investigation.

Ten open questions in migraine prophylaxis with monoclonal antibodies blocking the calcitonin-gene related peptide pathway: a narrative review

“…Erenumab or galcanezumab were also effective on migraine with aura in two patients with a mitochondriopathy [ 140 , 141 ] and galcanezumab was found effective in a patient with nummular headache [ 142 ].…”

Epicranial headaches part 2: Nummular headache and epicrania fugax

“…In addition to spontaneous pain, there may be sensory disturbances in the affected area. The description given for these disturbances is diverse, but in one form or another they can be found in many cases of NH (1,4,6,(10)(11)(12)(13)(14)16,(20)(21)(22)(23)(24)(25)(26)(27)29,31,35,39,41,42,47,48,51,53,(57)(58)(59)(60)(63)(64)(65)(66). In one of the largest series, sensory symptoms or signs were detected in more than 40% of cases (33).…”

“…Exacerbations of baseline pain are frequent (4,9,12–14,16,18,21–23,26,32,33,40,53,56,58–60,63,64,66). These exacerbations sometimes occur spontaneously and sometimes are triggered by the application of light stimuli to the symptomatic area (touch, combing, etc.…”

“…NH frequently coexists with other primary headaches, particularly migraine (1,4,5,13,(19)(20)(21)(23)(24)(25)35,53,60,62,66). However, when this occurs, migraine and NH present independently and without a clear causal relationship.…”

“…NH may be considered an unusual type of headache, but it is not exceptional. To date, about 540 different cases have been described in full-length papers, with some of these cases being included in more than one paper (1,4–66). The gender distribution has shown a female predominance, with a ratio of 1.6:1.…”