13 Surgical Treatment of Nummular Headaches (Site VII)

10.1055/b-0038-161694

13 Surgical Treatment of Nummular Headaches (Site VII)

Bahman Guyuron

Salient Points

Nummular headache (NH) is a disorder in which pain is localized to a specific area.
NH is a rare disorder occurring with an estimated incidence of 6.4 to 9/100,000 in a hospital-based series.
ICHD-3 beta describes NH as a sharply contoured pain of highly variable duration, but often chronic, in a small circumscribed area (1-6 cm) of the scalp.
The pain is often in a round or elliptical-shaped area. It typically occurs in the parietal region and tends to be “side locked.”
The patient can usually point to a distinct and constant spot.
An ultrasound vascular Doppler signal can almost invariably be detected.
A positive response to a nerve block could be extremely informative so long as the patients report headaches at the time of office visit.
Surgery is performed under local anesthesia and involves a 5- to 10-mm incision and removal of a small vessel with or without removal of a terminal nerve branch.
The incision is repaired with 6-0 Monocryl and 5-0 or 6-0 plain catgut depending on the site.
Surgery almost uniformly results in elimination of headaches in the operated site.
There is a small chance of NH developing in the vicinity of the previous surgery site, but never exactly in the same area.

13.1 Introduction

Nummular headache (NH) is a rare disorder occurring with an estimated incidence of 6.4 to 9/100,000 in a hospital-based series, ¹ ^, ² nevertheless, this entity seems more common post-migraine surgery than statistics suggest. The International Classification of Headache Disorders, third edition, beta version (ICHD-3 beta) describes NH as a sharply contoured pain of highly variable duration, but often chronic, in a small circumscribed area of the scalp. The pain is often in a round or an elliptical-shaped area. While it typically occurs in the parietal region, it can be anywhere on the scalp. Over-the-counter analgesics are commonly adequate to treat most NH patients. Sometimes the pain is severe, necessitating additional modalities. ³ ^, ⁴

13.2 Detection of the Trigger Site

The patient is asked to point to the trigger site, and the area is marked. Almost invariably, a vascular signal can be detected with ultrasound Doppler. Occasionally, it is necessary to move the Doppler probe around a few millimeters outside of where the patient points to find the signal. The signal site is then marked. Should the patient report headache at the time of the office visit, the Doppler signal site is injected with 0.5 mL of Naropin. A positive response to a nerve block could be extremely informative as long as the patient reports having a headache at the time of the office visit. A negative nerve block does not mean that surgery will not be effective in the injected site.

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