Cefalea atribuida a ictus isquémico. Actualización semiológica y diagnóstica / Headache attributed to ischaemic stroke. An update on its semiology and diagnosis

Introducción: La cefalea es un síntoma frecuente tras el ictus isquémico agudo. Su identificación y diagnóstico constituyen un reto por el perfil de paciente y los criterios diagnósticos actuales de esta entidad. Los objetivos del estudio fueron determinar la prevalencia de cefalea atribuida a ictus isquémico y su forma persistente, y analizar las variables clinicodemográficas y el grado de cumplimiento de los criterios de la Clasificación Internacional de Cefaleas (ICHD-III). Pacientes y métodos: Es un estudio observacional analítico de cohortes prospectivo de pacientes ingresados con ictus isquémico agudo en la unidad de ictus de un hospital de tercer nivel en un período de 12 meses. Resultados: Se incluyó a 244 pacientes con ictus isquémico agudo (el 59,8%, varones; edad media: 71 ± 12,8 años). El 23,2% presentó cefalea en el momento del ingreso o bien en las primeras 72 horas y el 12,5% de ellos presentó cefalea persistente atribuida a ictus isquémico. El 62,5% cumplió los criterios diagnósticos de acuerdo con la ICHD-III. Conclusión: La cefalea tras el ictus isquémico es un síntoma frecuente. Su aparición se asoció al sexo femenino, al ictus de territorio vertebrobasilar y a puntuaciones bajas en la National Institutes of Health Stroke Scale. Sería recomendable revisar los criterios diagnósticos actuales.(AU)

Introduction: Headache is a common symptom in acute ischemic stroke which is often overlooked and undertreated because of focus in neurologic function, communication difficulties in stroke patients and the current diagnostic criteria of this type of headache. The present study aimed to determine the prevalence of Acute and Persistent Headache Attributed to Ischemic Stroke and to analyze the fulfillment of the criteria of the International Classification of Headaches (ICHD-IID). Patients and methods: Prospective observational analytical cohort study. The study population consisted of patients with acute ischemic stroke admitted to the Stroke Unit of a tertiary care hospital over a period of 12 months. Results: Two hundred and forty-four patients with acute ischemic stroke (59.8% males, mean age 71+12.8 years) were included. Headache at onset or at the first 72 hours was present in 23.2% and 12.5% of them presented persistent headache attributed to ischemic stroke. Only 62.5% of the headaches at stroke onset fulfilled the diagnostic criteria of ICHD-III. Conclusion: Headache after ischemic stroke is a common symptom. It was associated with female sex, posterior circulation stroke and low scores on the National Institutes of Health Stroke Scale (NIHSS). The current diagnostic criteria should be reviewed.

VA/DoD clinical practice guideline for the management of headache

The VA and DoD Evidence-Based Practice Work Group (EBPWG) was established and first chartered in 2004, with a mission to advise the VA/DoD Health Executive Committee "on the use of clinical and epidemiological evidence to improve the health of the population . . ." across the Veterans Health Administration (VHA) and Defense Health Agency (DHA), by facilitating the development of CPGs for the VA and DoD populations. Development and update of VA/DoD CPGs is funded by VA Evidence Based Practice, Office of Quality and Patient Safety. The system-wide goal of evidencebased CPGs is to improve patient health and wellbeing. In July 2020, the VA and DoD published a CPG for The Primary Care Management of Headache (2020 VA/DoD Headache CPG), which was based on evidence reviewed through March 2019. Since the release of that CPG, the evidence base on Headache has expanded. Consequently, the EBPWG initiated the update of the 2020 VA/DoD Headache CPG in 2023. This updated CPG's use of Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach reflects a more rigorous application of the methodology than previous iterations.(2) Therefore, the strength of some recommendations may have been modified due to the confidence in the quality of the supporting evidence (see Evidence Quality and Recommendation Strength). This CPG provides an evidence-based framework for evaluating and managing care for individuals living with Headache toward improving clinical outcomes. Successful implementation of this CPG will: • Assess the patient's condition and collaborate with the patient, family, and caregivers to determine optimal management of patient care; • Emphasize the use of patient-centered care and shared decision making; • Minimize preventable complications and morbidity; and • Optimize individual health outcomes and quality of life (QoL).

Avaliação do manejo médico no atendimento de cefaleia na sala de urgência e emergência do Hospital Regional de Barbacena - MG / Evaluation of medical management in the treatment of headache in the urgency and emergency room of the Hospital Regional de Barbacena - MG

Introdução: O manejo da cefaleia nas salas de urgência e emergência deve ser baseada em uma anamnese detalhada para que o diagnóstico e tratamento sejam adequados, entretanto não é o que se encontra nos atendimentos. Objetivo: Avaliar o manejo do atendimento das cefaleias em uma sala de Urgência e Emergência. Métodos: Estudo de corte transversal retrospectivo, realizado através da análise de dados de 1317 prontuários eletrônicos de pacientes com queixa de cefaleia que procuraram o serviço de emergência do Hospital Regional de Barbacena durante o período de 01 de janeiro de 2017 a 30 de junho de 2019. Os diagnósticos relatados nos prontuários foram classificados de acordo com os critérios da Classificação Internacional das Cefaleias (ICHD-3). Os dados foram submetidos à análise estatísticas, pelo teste de qui-quadrado. Considerou-se diferenças estatisticamente significativas aquelas cujo valor p≤0,05. Resultados: Do total de prontuários, três foram excluídos, sendo analisados 1314. Entre os prontuários analisados, 73,21% apresentaram diagnósticos iniciais eram cefaleia, 16,67% migrânea e 10,12% cefaleia do tipo tensão. Já no diagnóstico final, cefaleia correspondeu a 59,67%, migrânea a 17,95% e cefaleia do tipo tensão a 8,52%. Em relação ao tratamento, foi receitado opioides para 43,99% dos pacientes e para o restante foram prescritos medicamentos não opioides. Conclusão: O trabalho sugeriu falha no manejo da cefaleia nas salas de urgência e emergência, provavelmente pela limitação do conhecimento dos profissionais de saúde acerca da dor de cabeça. O que acarretou no grande número de diagnósticos inespecíficos e inadequada abordagem terapêutica.

Introduction: Detailed clinical evaluation should be the basis for the proper management of headaches in emergency rooms, in order to allow adequate diagnosis and treatment. However, this is not usually observed on clinical rounds. Objective: To evaluate the management of headache consultations in an emergency rooms. Methods: This is a cross-section study was performed analyzing data from 1,317 electronic medical records of patients with headache complaints who sought treatment at the Barbacena City Regional Hospital's between January 1, 2017, and June 20, 2019. Medical records were classified according to the International Classification of Headache Disorders (ICHD-3). The data collected were statistically analyzed using chi-square tests. The study considered a p-value≤0.05 to define statistically significant differences. Results: Three medical records were excluded and 1,314 were analyzed. Among the medical records analyzed, 73.21% of initial diagnoses were classified as headache, 16.67% as migraine, and 10.12% as tension-type headache. Headache corresponded to 59.76% of final diagnoses, migraine to 17.95%, and tension-type headache to 8.52%. Regarding the treatment, 43.99% of patients were prescribed opioids for the remaining were prescribed nonopioid medications. Conclusion: The study suggests that the management of headaches is inadequate in emergency rooms, probably due to limited knowledge of health professionals about headache. This resulted in a large number of nonspecific diagnoses and inadequate therapeutic approaches.

Classifying migraine subtypes and their characteristics by latent class analysis using data of a nation-wide population-based study.

Migraine neither presents with a definitive single symptom nor has a distinct biomarker; thus, its diagnosis is based on combinations of typical symptoms. We aimed to identify natural subgroups of migraine based on symptoms listed in the diagnostic criteria of the third edition of the International Classification of Headache Disorders. Latent class analysis (LCA) was applied to the data of the Korean Sleep-Headache Study, a nationwide population-based survey. We selected a three-class model based on Akaike and Bayesian information criteria and characterized the three identified classes as "mild and low frequency," "photophobia and phonophobia," and "severe and high frequency." In total, 52.0% (65/125) of the participants were classified as "mild and low frequency," showing the highest frequency of mild headache intensity but the lowest overall headache frequency. Meanwhile, "photophobia and phonophobia" involved 33.6% (42/125) of the participants, who showed the highest frequency of photophobia and phonophobia. Finally, "severe and high frequency" included 14.4% (18/125) of the participants, and they presented the highest frequency of severe headache intensity and highest headache frequency. In conclusion, LCA is useful for analyzing the heterogeneity of migraine symptoms and identifying migraine subtypes. This approach may improve our understanding of the clinical characterization of migraine.

Distinguishing persistent post-traumatic headache from migraine: Classification based on clinical symptoms and brain structural MRI data.

BACKGROUND: Persistent post-traumatic headache most commonly has symptoms that overlap those of migraine. In some cases, it can be clinically difficult to differentiate persistent post-traumatic headache with a migraine phenotype from migraine. The objective of this study was to develop a classification model based on questionnaire data and structural neuroimaging data that distinguishes individuals with migraine from those with persistent post-traumatic headache. METHODS: Questionnaires assessing headache characteristics, sensory hypersensitivities, cognitive functioning, and mood, as well as T1-weighted magnetic resonance imaging and diffusion tensor data from 34 patients with migraine and 48 patients with persistent post-traumatic headache attributed to mild traumatic brain injury were included for analysis. The majority of patients with persistent post-traumatic headache had a migraine/probable migraine phenotype (77%). A machine-learning leave-one-out cross-validation algorithm determined the average accuracy for distinguishing individual migraine patients from individual patients with persistent post-traumatic headache. RESULTS: Based on questionnaire data alone, the average classification accuracy for determining whether an individual person had migraine or persistent post-traumatic headache was 71.9%. Adding imaging data features to the model improved the classification accuracy to 78%, including an average accuracy of 97.1% for identifying individual migraine patients and an average accuracy of 64.6% for identifying individual patients with persistent post-traumatic headache. The most important clinical features that contributed to the classification accuracy included questions related to anxiety and decision making. Cortical brain features and fibertract data from the following regions or tracts most contributed to the classification accuracy: Bilateral superior temporal, inferior parietal and posterior cingulate; right lateral occipital, uncinate, and superior longitudinal fasciculus. A post-hoc analysis showed that compared to incorrectly classified persistent post-traumatic headache patients, those who were correctly classified as having persistent post-traumatic headache had more severe physical, autonomic, anxiety and depression symptoms, were more likely to have post-traumatic stress disorder, and were more likely to have had mild traumatic brain injury attributed to blasts. DISCUSSION: A classification model that included a combination of questionnaire data and structural imaging parameters classified individual patients as having migraine versus persistent post-traumatic headache with good accuracy. The most important clinical measures that contributed to the classification accuracy included questions on mood. Regional brain structures and fibertracts that play roles in pain processing and pain integration were important brain features that contributed to the classification accuracy. The lower classification accuracy for patients with persistent post-traumatic headache compared to migraine may be related to greater heterogeneity of patients in the persistent post-traumatic headache cohort regarding their traumatic brain injury mechanisms, and physical, emotional, and cognitive symptoms.

Headache and neck.

Cervicogenic headache (CEH) is currently identified with different diagnostic criteria. The latest one is the International classification of headache disorders (ICHD), 3rd edition (2018). At the present time, there are not enough published articles with reliable sensitivity and specificity that may support a classification for clinical and research purposes. Current literature suggests improvement to the classification(s). The ICHD criteria should be modified to reach an optimal sensitive and specific level to identify CEH as a secondary headache. The B, C1, and C2 criteria should be implemented with proposed suggestions. The C3 criterion should be upgraded. Criteria such as mechanical precipitation of pain by digital pressure on neck trigger points and specific movements, strictly unilateral pain without side-shift, diffuse unilateral shoulder and arm pain, pain starting posteriorly and spreading anteriorly should be integral part of the classification.

Headaches in Adults in Primary Care: Evaluation, Diagnosis, and Treatment.

Headaches are common in primary care. The diagnosis is made by a careful history and physical examination. Imaging is generally not warranted. Several general principles underlie the acute treatment of headache: early initiation of therapy and adequate dosing at first dose. Careful attention to avoiding too frequent administration of acute therapy is important to avoid medication overuse headaches. Opioids should always be avoided. Preventive treatment is indicated for frequent headaches. Successful treatment entails low-dose medication with careful titration and monitoring of headache frequency. Behavioral strategies are important and should be part of any comprehensive headache management plan.

Update on headache and brain tumors.

Headache is one of the leading symptoms often associated with brain tumours. Secondary headaches attributed to intracranial neoplasias have been included in subchapter 7.4 of the third edition of the International Classification of Headache Disorders (ICHD-3). According to ICHD-3, the headache may be attributed to a brain tumour if it has developed in close temporal relation with the development of the neoplasia, has significantly worsened in parallel with the worsening of the tumour, and/or has significantly improved following the successful treatment of the neoplasia. Brain tumour headache was traditionally thought to display some specific clinical characteristics, including worsening in the morning and/or when lying down, being aggravated by Valsalva-like manoeuvres and accompanied by nausea and/or vomiting; however, the studies performed after the advent of modern neurodiagnostic techniques have pointed out that the "classic" brain tumour headache is uncommon, particularly at the time of clinical presentation. Therefore, it becomes critical to seek some specific factors associated with the presence of an intracranial mass (the so-called "red flags") that can guide the physician to establish an accurate diagnosis.

Phenotypic characterization of acute headache attributed to SARS-CoV-2: An ICHD-3 validation study on 106 hospitalized patients.

INTRODUCTION: Headache is a common symptom of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In this study, we aimed to characterize the phenotype of headache attributed to SARS-CoV-2 infection and to test the International Classification of Headache Disorders (ICHD-3) phenotypic criteria for migraine and tension-type headache. METHODS: The study design was a cross-sectional study nested in a cohort. We screened all consecutive patients that were hospitalized and had a positive SARS-CoV-2 test. We included patients that described headache if the headache was not better explained by another ICHD-3 diagnosis. Patients were interviewed by two neurologists. RESULTS: We screened 580 patients and included 130 (mean age 56 years, 64% female). Headache was the first symptom of the infection in 26% of patients and appeared within 24 hours in 62% of patients. The headache was bilateral in 85%, frontal in 83%, and with pressing quality in 75% of patients. Mean intensity was 7.1, being severe in 64%. Hypersensitivity to stimuli occurred in 57% of patients. ICHD-3 criteria for headache attributed to systemic viral infection were fulfilled by 94% of patients; phenotypic criteria for migraine were fulfilled by 25% of patients, and tension-type headache criteria by 54% of patients. CONCLUSION: Headache attributed to SARS-CoV-2 infection in hospitalized patients has severe intensity, frontal predominance and oppressive quality. It occurs early in the course of the disease. Most patients fulfilled ICHD-3 criteria for headache attributed to systemic viral infection; however, the phenotype might resemble migraine in a quarter of cases and tension-type headache in half of the patients.

A Historical Review of Headaches: Who First Described Them and When did This Occur?

BACKGROUND: Headache is as old as human history and has been able to report, and the first descriptions were found in Greece and Mesopotamia. OBJECTIVE: Our objective was to know the date of the first description of ICHD-3 headaches, with their respective author. METHODS: We searched for articles that addressed the historical aspects of primary and secondary headaches and painful cranial neuropathies. RESULTS: Twenty-seven different headaches were analyzed according to the occurrence of their first description, with the respective author and country of origin. CONCLUSIONS: The knowledge of the first description of ICHD-3 headaches, with their respective author, showed us how and when the different headaches appeared over the years.

Machine learning-based automated classification of headache disorders using patient-reported questionnaires.

Classification of headache disorders is dependent on a subjective self-report from patients and its interpretation by physicians. We aimed to apply objective data-driven machine learning approaches to analyze patient-reported symptoms and test the feasibility of the automated classification of headache disorders. The self-report data of 2162 patients were analyzed. Headache disorders were merged into five major entities. The patients were divided into training (n = 1286) and test (n = 876) cohorts. We trained a stacked classifier model with four layers of XGBoost classifiers. The first layer classified between migraine and others, the second layer classified between tension-type headache (TTH) and others, and the third layer classified between trigeminal autonomic cephalalgia (TAC) and others, and the fourth layer classified between epicranial and thunderclap headaches. Each layer selected different features from the self-reports by using least absolute shrinkage and selection operator. In the test cohort, our stacked classifier obtained accuracy of 81%, sensitivity of 88%, 69%, 65%, 53%, and 51%, and specificity of 95%, 55%, 46%, 48%, and 51% for migraine, TTH, TAC, epicranial headache, and thunderclap headaches, respectively. We showed that a machine-learning based approach is applicable in analyzing patient-reported questionnaires. Our result could serve as a baseline for future studies in headache research.

Cefalea en trueno. Una entidad que debe ser rápidamente reconocida y estudiada / Headache in thunder. A condition that must be quickly recognised and studied

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Epidemiología de la migraña en España y Latinoamérica / Epidemiology of migraine in Spain and Latin America

INTRODUCCIÓN: La migraña es una enfermedad muy invalidante con un gran impacto en la calidad de vida del paciente e interferencia en su esfera personal, social, laboral y familiar. Desde un punto de vista histórico, la conexión entre la Península Ibérica y Latinoamérica ha sido muy importante, por lo que parece razonable que existan paralelismos en la epidemiología de esta enfermedad, dado el papel que determinados condicionantes genéticos y relacionados con el estilo de vida tienen en su historia natural. OBJETIVO: Revisar de forma detallada los estudios epidemiológicos descriptivos de la migraña en España y América Latina. DESARROLLO: Búsqueda bibliográfica de estudios de epidemiología sobre migraña en nuestro país y en los que conforman Latinoamérica. Se analiza la población estudiada, la metodología, el cuestionario utilizado para el diagnóstico y los datos de prevalencia. Se evaluaron un total de 23 estudios. CONCLUSIONES: No todos los países cuentan con estudios epidemiológicos de migraña de base poblacional y la mayor parte de ellos se desarrollaron hace más de diez años. La metodología aplicada es, además, muy heterogénea. Los datos de prevalencia obtenidos en los estudios seleccionados, con la excepción de algunos realizados en Brasil y Perú, son muy similares a los encontrados en España

INTRODUCTION: Migraine is a very disabling disease that has a great impact on patients’ quality of life and interferes in their personal, social, work and family spheres. From a historical point of view, the connection between the Iberian Peninsula and Latin America has been very important, and so it seems reasonable to find there are parallels in the epidemiology of this disease, given the role that certain genetic and lifestyle-related determinants have in its natural history. AIM: To conduct a detailed review of the descriptive epidemiological studies of migraine in Spain and Latin America. DEVELOPMENT. Literature search of epidemiological studies on migraine in our country and in Latin America. The population studied, the methodology, the questionnaire used for diagnosis and the prevalence data were analysed. Altogether 23 studies were evaluated. CONCLUSIONS: Not all countries have population-based epidemiological studies of migraine, and most of them were conducted more than 10 years ago. Moreover, a wide range of methodologies were applied. The prevalence data obtained in the selected studies, with the exception of some conducted in Brazil and Peru, are very similar to those found in Spain

Spectrum of Headaches Associated With SARS-CoV-2 Infection: Study of Healthcare Professionals.

BACKGROUND: Series of patients with SARS-CoV-2 infection report headache in 6%-15% of cases, although some data suggest that the actual frequency is higher, and that headache is not associated with fever. No study published to date has analyzed the characteristics of headache in these patients. OBJECTIVE: To analyze the characteristics of COVID-19 related headaches. METHODS: We conducted a survey of Spaniard healthcare professionals who have been infected by SARS-CoV-2 and presented headache during the course of the disease. The survey addressed respondents' medical history and headache characteristics, and we analyzed the association between both. RESULTS: We analyzed the responses of a sample of 112 healthcare professionals. History of migraine was reported by 20/112 (17.9%) of respondents, history of tension-type headache by 8/112 (7.1%), and history of cluster headache was reported by a single respondent; 82/112(73.2%) of respondents had no history of headache. Headache presented independently of fever, around the third day after symptom onset. The previous history of migraine was associated with a higher frequency of pulsating headache (20% in patients with previous migraine vs 4.3% in those with no history of migraine, P = .013). CONCLUSION: Headache is often holocranial, hemicranial, or occipital, pressing, and worsens with physical activity or head movements. Because the characteristics of the headache and the associated symptoms are heterogeneous in our survey, we suggest that several patterns with specific pathophysiological mechanisms may underlie the headache associated with COVID-19.

Sinus Headache: Differential Diagnosis and an Evidence-Based Approach.

The diagnosis "sinus headache" has been reclassified as "headache attributed to disorder of the nose or paranasal sinuses" by the International Headache Society, but the term is still commonly used by patients and primary care doctors alike. Rhinologic symptoms and headache disorders are common, and they may coexist without a causative relationship. Patients may undergo unnecessary medical interventions because of inadequate understanding of the classifications and management of various headache disorders. Otolaryngologists frequently treat patients with these complaints, and a systematic approach to the differential diagnosis and utilization of a multidisciplinary approach are critical in providing optimal patient care.

Evaluation and Treatment of Primary Headaches in Adolescents.

Headache is a common episodic and chronic pain syndrome in adolescents. Evaluation of headaches in primary care requires a comprehensive assessment including lifestyle behaviors and physical examination, as well as an understanding of when to pursue appropriate testing. Primary headache disorders seen in adolescents include migraine and tension-type headache. Pharmacologic management for primary headache includes both acute and prophylactic treatment strategies.

Cómo y cuándo derivar un paciente con cefalea primaria y neuralgia craneofacial desde Urgencias y Atención Primaria: recomendaciones del Grupo de Estudio de Cefalea de la Sociedad Española de Neurología / How and when to refer patients diagnosed with primary headache and craniofacial neuralgia in the Emergency department or Primary Care: Recommendations of the Spanish Society of Neurology's Headache Study Group

INTRODUCCIÓN: Cuando tras una correcta anamnesis y exploración neurológica se diagnostica a un paciente con una cefalea primaria o una neuralgia craneofacial en urgencias o atención primaria y se decide derivar a neurología por complejidad es útil conocer si además se deberían solicitar exploraciones complementarias y la preferencia (urgente, preferente o normal) con la que se debería derivar para que el paciente llegue a la consulta del neurólogo sin demoras innecesarias en pacientes con dolores incapacitantes o con sospecha de organicidad. Por este motivo, el Grupo de Estudio de Cefalea de la Sociedad Española de Neurología, ha decidido crear unas recomendaciones consensuadas que establezcan un protocolo de derivación de pacientes con cefalea y/o neuralgias craneofaciales. DESARROLLO: Se ha contactado con neurólogos jóvenes con interés y experiencia en cefalea y con la Junta Directiva del Grupo de Estudio de Cefalea de la Sociedad Española de Neurología que han desarrollado este documento que, por razones prácticas, se ha dividido en 2 artículos. Esta primera centrada en las cefaleas o neuralgias craneofaciales primarias y una segunda que se focaliza en las cefaleas secundarias. El enfoque es práctico con tablas que resumen los criterios de derivación con exploraciones complementarias y otros especialistas a los que derivar, para que sea útil y facilite su uso en nuestra práctica asistencial diaria. CONCLUSIONES: Esperamos ofrecer una guía y herramientas para mejorar la toma de decisiones ante un paciente con cefalea, valorando exploraciones a priorizar y qué circuitos seguir para así evitar la duplicación de consultas y retrasos en el diagnóstico y en el tratamiento

INTRODUCTION: When a patient is diagnosed with primary headache or craniofacial neuralgia in the emergency department or in primary care, and is referred to a neurologist due to the complexity of the case, it is useful to know whether additional examination should be sought and the priority (urgent, preferential or normal) with which the patient should be seen. This will avoid unnecessary delays in patients with disabling headache and where organic causes are suspected. In order to issue recommendations on this matter, the Spanish Society of Neurology's Headache Study Group has decided to create a series of agreed recommendations constituting a referral protocol for patients with headache and/or craniofacial neuralgia. DEVELOPMENT: Young neurologists with an interest and experience in headache were invited to draft a series of practical guidelines in collaboration with Spanish Society of Neurology's Headache Study Group Executive Committee. For practical reasons, the document was divided into 2 articles: this first article focuses on primary headaches and craniofacial neuralgias and the second on secondary headaches. In order for the recommendations to be helpful for daily practice they follow a practical approach, with tables summarising referral criteria, examinations to be performed, and referral to other specialists. CONCLUSIONS: We hope to offer a guide and tools to improve decision-making regarding patients with headache, identifying complementary tests to prioritise and referral pathways to be followed, in order to avoid duplicated consultations and delayed diagnosis and treatment

Descripción clínica y fisiopatológica de la cefalea numular: serie de casos / Clinical and pathophysiological description of nummular headaches: a case series

INTRODUCCIÓN: La cefalea numular se describió inicialmente como una cefalea primaria infrecuente caracterizada por dolor circunscrito crónico en una pequeña área craneal, de intensidad leve-moderada y que puede presentar exacerbaciones. Desde su descripción inicial se han publicado decenas de casos de cefalea numular que amplían el espectro clínico y fisiopatológico. OBJETIVOS: Revisar y establecer las características clínicas de la cefalea numular, analizar la epidemiología en nuestro medio y aclarar incógnitas fisiopatológicas. PACIENTES Y MÉTODOS: Se estudiaron 83 casos (42 mujeres y 41 varones), que fueron diagnosticados de cefalea numular desde julio de 2003 a julio de 2008, y seguidos hasta 2018 en el Hospital Universitario Fundación Alcorcón. La edad media de inicio fue de 46 años. El tiempo de evolución hasta el diagnóstico fue de siete meses. RESULTADOS: El dolor fue moderado-intenso y opresivo, con exacerbaciones en el 62,5% de los casos. El tamaño medio del área sintomática fue de 2,4 ± 0,7 cm, con una localización parietal (47%), temporal (24%), frontal (12%) u occipital (6%). Presentó un patrón crónico (82%) o episódico (18%). Mostraron síntomas de disfunción sensitiva local 25 pacientes, y otros tres, cambios en la piel. La remisión espontánea se observó en el 36% de los casos, y los fármacos más utilizados fueron los antiinflamatorios no esteroideos, el paracetamol y la gabapentina. La toxina botulínica fue eficaz. CONCLUSIONES: La cefalea numular es un trastorno con características bien definidas y con entidad propia. Nuestros datos indican que su origen está en las estructuras epicraneales. La conjunción de dolor, disfunción sensitiva y alteraciones tróficas indica una forma local de síndrome regional complejo

INTRODUCTION: Nummular headache was initially described as an infrequent primary headache characterised by chronic circumscribed mild-to-moderate pain in a small area of the head that may present with exacerbations. Since its initial description, dozens of cases of nummular headache have been reported which broaden the clinical and pathophysiological spectrum. AIMS. To review and establish the clinical characteristics of nummular headache, to analyse the epidemiology in our setting and to clarify some unanswered pathophysiological issues. PATIENTS AND METHODS: The study involved 83 cases (42 women and 41 men) who were diagnosed with nummular headache from July 2008 and followed up until 2018 at the Fundación Alcorcón Hospital. The mean age of onset was 46 years. The time to diagnosis was seven months. RESULTS: The pain was moderate-intense and oppressive, with exacerbations in 62.5% of cases. The average size of the symptomatic area was 2.4 ± 0.7 cm, with a parietal (47%), temporal (24%), frontal (12%) or occipital (6%) location. It presented a chronic (82%) or episodic (18%) pattern. Symptoms of local sensory dysfunction were observed in 25 patients and three others showed skin alterations. Spontaneous remission was observed in 36% of cases, and the most commonly used drugs were non-steroidal anti-inflammatory drugs, paracetamol and gabapentin. Botulinum toxin was effective. CONCLUSIONS: Nummular headache is a disorder with well-defined characteristics and is considered an entity in its own right. Our data indicate that its origin lies in the epicranial structures. The conjunction of pain, sensory dysfunction and trophic disorders suggests a local form of a complex regional síndrome