Bifocal Nummular Headache: A Series of 6 New Cases

Objective.-We aimed to report 6 new cases of bifocal nummular headache (NH), showing their clinical characteristics and comparing them with those formerly described. Background.-NH is a focal head pain felt in a small, well-circumscribed, coin-shaped area. Among all the reported cases (over 200), 6 patients localized their pain in 2 or more separate areas. Methods.-We reviewed all patients diagnosed with NH at the headache clinics of 2 tertiary hospitals, searching for cases with head pain in 2 different areas. Results.-Six patients (4 female, 2 male; age at onset 40.8 +/- 19.1, range 24-69 years) presented with bifocal NH. The shape and size of both painful areas were identical in each patient. They were located at symmetrical points of either side in 3 patients, while 2 patients had both symptomatic areas on the same side of the head. The chronological pattern was synchronous in 2 patients, and the other 4 showed an additive pattern with onset intervals between the 2 areas ranging from 2 months to 30 years. Pain intensity was slightly different in each area in 4 of the cases. Four patients were treated with a preventive (gabapentin or carbamazepine) with good clinical response. Conclusion.-Although not frequently found, some patients may have bifocal or multifocal NH.