Headache is one of the oldest and most common health problems in human history. Almost everyone experiences this complaint at some point in their life. Pains generally described as encompassing the entire head, throbbing or squeezing, are associated with familiar conditions such as migraine or tension-type headache. However, there are also special headache types defined in recent years that can be considered new even for neurology specialists. Among these rare forms, Nummular Headache stands out with its distinctive appearance and limited pain area. This disease, which takes its name from the Latin word nummulus meaning “coin,” holds a separate place in the headache spectrum. This article aims to introduce this lesser-known condition among headache disorders in an understandable way and to enlighten with accurate information.

Nummular headache is a rare type of headache that typically progresses with pain in a circular or oval shape in such a small area on the scalp that it can be pointed to with a finger. The pain is most often felt always at the same point and does not change location. It can be experienced continuously or in attacks; it can vary from a mild aching sensation to moderate pain affecting daily life. Some patients describe this area as sensitive to touch, sometimes with a tingling or burning sensation. Unlike migraine or tension-type headache, it is distinguished by its localized character and stable pain area.

What is Nummular Headache?

Nummular Headache is a highly localized and distinctive type of headache defined by the International Headache Society (IHS) in the “primary headache” category. The Latin word “nummulus” means “small coin” and this name reflects that the pain is felt in a limited, round or elliptical shaped, clearly demarcated area. This rare headache type typically causes pain in a coin-sized spot on the scalp. The fact that the pain remains limited to a specific area and does not spread to the surroundings is the most characteristic feature that distinguishes Nummular Headache from other common headache syndromes (migraine, tension-type headache, etc.).

Unlike other types of headaches, Nummular Headache is not felt as throbbing pains encompassing the entire head, but in an area so distinct it can be pointed to with a finger. Patients generally describe it as “a spot the size of a coin on my head constantly hurts.” The pain is typically in a fixed area 1 to 6 centimeters in diameter; sometimes continuous, sometimes occurring in attacks. This condition means that the pain itself is the disease without being a symptom of another illness. That is, Nummular Headache is a primary (primary) headache syndrome that develops without an underlying cause and is accepted as a distinctive clinical picture among headache disorders.

What Causes Nummular Headache?

The exact cause of Nummular Headache has not yet been fully elucidated. However, current scientific data suggest that this condition may be related to a local sensitivity of nerve endings in the scalp (scalp) rather than a central nervous system problem. According to the most accepted theory, pain signals become continuous as a result of local irritation or microscopic-level nerve damage of one or more of the small sensory nerve branches that supply the scalp. This explains the limited coin-shaped pain area. Especially the fact that the regions where pain is frequently seen overlap with the terminal branches of the trigeminal nerve that carries the sensation of the face and front part of the head suggests that this nerve network may play a role in nummular headache.

Some researchers have also suggested that there may be microscopic pathologies at the local bone or soft tissue level at the origin of the pain. Nerve compression or inflammatory changes in the skull bone or subcutaneous tissues can trigger this condition. However, in detailed imaging examinations performed, a distinct structural abnormality is often not detected. In summary, Nummular Headache is accepted as a limited peripheral nerve-originated pain syndrome located in the scalp rather than a central brain disease.

Who Gets Nummular Headache?

Nummular Headache is a quite rare type of headache in the general population. Although it can occur at any age, it has most commonly been described in middle-aged and older adults, especially in the 40-60 age range. It tends to be seen slightly more frequently in women than in men. This gender difference is thought to be related to hormonal and genetic factors.

Some patients may also have a history of another headache disorder such as migraine or tension-type headache. However, this is not a prerequisite for the occurrence of nummular headache. In most cases, it develops without any systemic disease or obvious risk factors. Therefore, nummular headache is generally accepted as a primary (distinctive and independent) headache syndrome.

What Are the Symptoms of Nummular Headache?

Nummular Headache has a distinctive and quite characteristic clinical picture. These distinctive symptoms that enable easy differentiation from other types of headaches can be summarized as follows:

• Location and Shape of Pain:
  The most typical feature of nummular headache is the presence of a pain area on the skull of coin size, with sharply defined boundaries. This region is usually unilateral and in most patients is located in the parietal (side-upper part of the head) region. More rarely, it can also be seen in the forehead, temple, or nape areas. Some patients may have more than one small pain focus.
• Character of Pain:
  The pain is mostly in the form of continuous aching, pressure, or burning sensation. On top of this, from time to time, stabbing or electric shock-like brief pain attacks lasting a few seconds to minutes can occur. These attacks are described as neuralgiform pain and can create a sharp discomfort in patients.
• Severity of Pain:
  The basic pain is generally mild-moderate level and does not completely prevent daily life activities. However, sharp attacks superimposed sometimes create short-term but more intense pain episodes. This can become disturbing especially in work requiring concentration.
• Sensory Changes:
  In approximately half of patients, hypersensitivity to touch (allodynia), perceiving normal touch as painful (hyperesthesia), or conversely decreased sensation (hypoesthesia) is seen in the painful area. Therefore, combing hair, using accessories that touch the head, or touching that area can increase pain.
• Duration and Course:
  Nummular headache is generally chronic. It can last for weeks, months, or even years. In some patients, the pain can spontaneously lighten and then intensify again, which creates the undulating character of the disease.

International Classification of Headache Disorders (ICHD-3) Diagnostic Criteria – 4.8 Nummular Headache

1. Presence of localized headache felt in a circular or oval shaped, well-demarcated area on the skull, scalp, or soft tissues of the head.
2. The character of pain must carry at least two of the following:
3. The pain area remains in a fixed location (does not change location).
4. The pain area is 1-6 cm in diameter.
5. Pain can be continuous or in attacks, but is always in the same area.
6. Sensory changes (increased sensitivity, loss of sensation, or tingling) may accompany the painful area.
7. Pain cannot be explained by other headache disorders (e.g., migraine, tension-type, neuralgias).
8. Another structural or systemic cause must be excluded (e.g., tumor, infection, subcutaneous lesion, trauma).

Additional Clinical Features (Supporting Findings)

• Pain is usually unilateral.
• Mostly located in the parietal region.
• Sensitivity (allodynia) occurs with touching the painful area.
• Pain is moderate severity and usually in the form of continuous aching or burning sensation.
• Outside the painful area, usually completely normal sensation is received.

How is Nummular Headache Diagnosed?

Nummular Headache diagnosis is largely based on the typical pain history told by the patient and localized sensitivity findings detected in neurological examination. However, since such limited headache can be confused with some serious diseases, these conditions need to be carefully excluded in the diagnostic process. Diagnosis is generally made with the following steps:

1. Detailed Patient History (Anamnesis):
   The most valuable information in diagnosing nummular headache is how the patient describes the pain. Your doctor inquires about the exact location, onset time, character, and duration of the pain. The patient being able to clearly indicate the painful area with their finger is one of the most typical clues suggesting this syndrome. The pain being at a fixed point distinguishes nummular pain from other headaches.
2. Physical and Neurological Examination:
   Neurological examination is generally normal, but sensitivity to touch, tingling, or decreased sensation may be detected in the painful area. These findings show that the pain really originates from a limited nerve area in the scalp.
3. Exclusion of Secondary Causes:
   The most critical stage in diagnosis is the elimination of other structural or systemic diseases that may cause pain. Because some medical conditions can lead to such limited pain on the skull:
   • Skull Lesions: Benign/malignant bone tumors, metastases, or infections (e.g., osteomyelitis).
   • Skin and Subcutaneous Lesions: Cysts, lipomas (fatty masses), or other subcutaneous formations.
   • Systemic Diseases: Systemic diseases affecting bone such as multiple myeloma.
   • Local Traumas: Small impacts the patient is unaware of or past injuries.
4. Imaging Methods:
   To exclude these secondary causes, Brain and Skull Bone Magnetic Resonance Imaging (MRI) is performed in most patients. MRI evaluates both brain tissue and skull bone and scalp in detail. If no pathology explaining the pain is seen on MRI and the patient’s history is typical, Nummular Headache diagnosis is confirmed. In some cases, especially if there is suspicion of bone origin, additional tests such as 3D Computed Tomography (CT) may also be requested.

Nummular Headache Treatment

Treatment of Nummular Headache is planned according to the severity, frequency of pain, and how much it affects the patient’s daily life. In some patients, since the pain progresses at a mild and tolerable level, only information and assurance that the disease is benign may be sufficient. However, in cases where pain significantly impairs quality of life, various pharmacological, injection-based, and supportive treatment options can be applied.

Pharmacological (Medication) Treatments

• Neuropathic Pain Medications:
  The most effective drug group in nummular headache is neuromodulators used for nerve-originated pains. Especially Gabapentin is the most frequently preferred drug with the most successful results reported. Treatment generally starts with a low dose and is gradually increased according to tolerance. Alternatively, Pregabalin or tricyclic antidepressants (e.g., Amitriptyline) are also among effective options.
• Anti-inflammatory Drugs (NSAIDs):
  Standard painkillers (e.g., ibuprofen, naproxen) generally show limited effect; however, in patients with mild symptoms, short-term trials can be made.

Local Injections

• Botulinum Toxin (Botox) Application:
  In resistant nummular headache cases that do not respond to drug therapy, Botox injections can be an effective option. Low-dose botulinum toxin applied to the painful area reduces pain by blocking excessive transmission at nerve endings. Clinical observations show that this method can significantly reduce both pain frequency and severity.
• Local Anesthetic or Steroid Injections:
  Local anesthetic (lidocaine, bupivacaine) or steroid injections applied to the limited area where pain is intense can provide temporary or sometimes permanent relief by suppressing nerve irritation.
  • Nerve blocks are especially applied to the occipital nerve or terminal nerve branches in the painful area. This procedure is used for both diagnostic and therapeutic purposes.

Other Treatment Approaches

• Topical Applications:
  Creams containing Lidocaine or capsaicin can provide regional relief by reducing hypersensitivity at nerve endings. Regular use is reported to be beneficial especially in patients with mild symptoms.
• Lifestyle and Supportive Approaches:
  Small changes such as sleep pattern, stress control, avoiding the use of accessories that put excessive pressure on the scalp (tight hat, bandana, etc.) can prevent triggering of pain.

In conclusion, Nummular Headache is generally a benign headache syndrome. Although it presents a rare and unusual clinical picture, effective treatment options are available when correctly diagnosed. Patients can often control their pain with appropriate drug therapy, local injections, or nerve blocks and significantly increase their quality of life.

Frequently Asked Questions About Nummular Headache

Is it normal for only a coin-sized spot on my head to hurt? Is this really a type of headache?

Yes. This condition is a primary headache syndrome defined in medical literature as “Nummular Headache”. The fact that the pain is felt in a round or oval area so limited it can be pointed to with a finger instead of spreading throughout the head is specific to this condition. This syndrome, recognized by the International Headache Society (IHS), is a benign type of headache although rare.

Could this pain I feel at a single point on my head be a symptom of a brain tumor or another dangerous condition?

Such limited pain can naturally create anxiety. Doctors primarily evaluate to exclude secondary causes (such as skull bone lesion, infection, subcutaneous mass, or brain tumor). In this process, imaging methods such as Brain MRI are generally used. If these tests come out clean and the type of pain is typical, the diagnosis is made as Nummular Headache. In this case, there is no dangerous disease.

Sometimes I get momentary needle-stick or electric shock-like pains in my head. Is this Nummular Headache?

This description is generally consistent with “Primary Stabbing Headache” (ice-pick headache); these types of pains are momentary and variable in location. In Nummular Headache, however, the pain is always in the same, fixed, and clearly demarcated area. In this area, there is usually continuous aching or pressure sensation and sometimes stabbing attacks can be superimposed. The distinguishing feature is that the pain is persistently always at the same “coin”-shaped point.

Which doctor should I go to for this headache and is there treatment?

The specialty to consult for this type of pain is Neurology. The neurology specialist confirms the diagnosis by performing necessary examinations and tests and creates an appropriate treatment plan.
Treatment is often possible. Neuropathic pain medications (e.g., Gabapentin, Pregabalin, Amitriptyline) generally respond well. In resistant cases, successful results can be obtained with Botox (Botulinum toxin) injections or nerve block applications.

Is Nummular Headache permanent, or does it pass over time?

The course of the disease varies from person to person. It generally shows a chronic (long-term) characteristic; it can last for months or even years. In some patients, the pain can spontaneously lighten or completely disappear, then start again. In others, it can continue with low intensity despite treatment. Good news: with appropriate treatment, the severity and frequency of pain can be largely controlled, quality of life increases significantly. In long-term follow-up studies, it has been reported that the pain area becomes inactive in approximately half of patients (approximately 48%). This shows that improvement can be achieved with treatment and follow-up.

Is Nummular Headache related to migraine?

Some patients may have a migraine history, but Nummular Headache is not the same as migraine. Migraine generally affects a large area of the head, is throbbing, and progresses with symptoms such as nausea, light or sound sensitivity. Nummular Headache, however, is limited to a small, fixed area and is a different clinical picture in this respect.

Does this pain lead to permanent brain damage?

No. Nummular Headache does not cause permanent damage to brain tissue. MRI images are generally normal. The pain originates from the sensitivity of nerve endings in the scalp; therefore, there is no risk of permanent neurological loss.

Can nummular headache be treated?

Yes. Nummular Headache is generally a benign type of headache and can be controlled with appropriate treatment approaches. Studies have reported that neuropathic pain medications such as Gabapentin and Amitriptyline, as well as OnabotulinumtoxinA (Botox) injections, are beneficial.

Is Botox or nerve block treatment safe?

Yes. These treatments have been used safely for many years in headaches and nerve-originated pains. Botox blocks pain transmission from nerve endings, while nerve block blocks the nerve’s hyperexcitability. When applied by an experienced neurology specialist, the complication risk is low and significant relief is achieved in most patients.

Is Botox or nerve block treatment really effective?

Yes. Especially in cases that do not respond to treatment, Botox injections and local nerve blocks can be effective. In literature, over 50% response rates are reported in groups receiving onabotulinumtoxinA.

Can this pain be confused with other types of headaches?

Yes, nummular headache can sometimes be accompanied by migraine or tension-type headache. A history of migraine or tension-type headache is also reported in some patients. However, the difference of nummular headache is that typically the pain is in a small, fixed, and distinct area.

In conclusion:

Although Nummular Headache is rare, it is a benign type of headache that can be controlled with correct diagnosis and treatment. If your pain is localized, at a fixed point, and has been continuing for a long time, consulting a neurology specialist is the most appropriate approach.