Had one case where I treated unrelenting headache with repeated IV Dihydroergotamine and metoclopramide just to find, as patient settled, that headache originated from a painful patch on the scalp called nummular headache. This is often due to a crushed nerve in area with nerve damage pain in a circular/oblong area. This triggered the unrelenting migraines which overshadowed it. Nummular patch headaches can respond to botulinum sometimes but other treatments are lackluster. Now it look like palmitoylethanolamide (PEA) combined with topiramate might do the trick.
Chirchiglia, Domenico, et al.
Administration of palmitoylethanolamide in combination with topiramate in the preventive treatment of nummular headache.
International Medical Case Reports Journal 9 (2016): 193- 195
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4957685/pdf/imcrj-9-193.pdf
Nummular headache are:
- generally in the parietal scalp
- in a small area like a coin, usually 2–6 cm in diameter
- pain often mild to moderate
- dull, burning, pressing or burning can occur but can also have stabbing jabs
- can be associated with occipital neuralgia which can be amenable to injection:
Neurol Neurochir Pol. 2014;48(2):141-3. doi: 10.1016/j.pjnns.2013.09.005.
Nummular headache in a patient with ipsilateral occipital neuralgia–a case report.
Iwanowski P et al
“Injection of bupivacaine twice to the right occipital region resulted in neuralgia resolution up to three months, with no effect on NH(nummular headache)”
Botulinum toxin injection has gotten press for its ability to settle the pain.
gabapentin has been tried
Trucco, Marco. “Nummular headache: another case treated with gabapentin.” The journal of headache and pain 8.2 (2007): 137-138.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3476124/pdf/10194_2007_Article_375.pdf
Oral meds are generally lackluster but PEA combined with Topirimate covers both neuropathic and migraine components:
Chirchiglia, Domenico, et al.
Administration of palmitoylethanolamide in combination with topiramate in the preventive treatment of nummular headache.
International Medical Case Reports Journal 9 (2016): 193- 195
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4957685/pdf/imcrj-9-193.pdf
they used 600 mg PEA and 100 mg topirimate. The neuropathic dose for PEA is usually 600 – 2000 mg (4-5/day of 400 mg) so I would suggest one start with at least 800 mg twice daily and hold that for 5 weeks and see.
Addendum- I now find 50% alcohol blocks work well as well
Thank-you for your posts. I really appreciate them. Is PEA available now to purchase in Canada? Where do you find is the best for your patients to access this? Thanks.
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Deanne,
Re Palmitoylethanolamide (PEA)
You can get it off Amazon.com but NOT off Amazon.ca and I doubt Amazon.com will ship it to Canada. I used to have to get it from Europe (using Ebay) but there are many vendors in USA that are reasonably priced. Suggestion – some items, especially if you get several bottles, might not make it past customs. So I routinely have patients have it sent C/O my office – ie ask your doctor if s/he while allow you to C/O the doctor’s office – there is now plenty of literature on its usefulness and there should be no argument there.
M. Montbriand MD