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25 years
Some parts of my head hurt sometimes when I touch them as if I had a bump. Also sometimes when I bend downward I feel pain inside the head but not like headaches. Which specialist should I see?
Nov 2, 2014

Dr. Zakia Dimassi Pediatrics
A/ Let me start with the feeling of heaviness in your head when upon leaning forward or bending forward: this could be due to a form of sinus congestion secondary to allergy or inflammation; if you have symptoms of allergic rhinitis (persistent runny nose, itching, sneezing) and post-nasal drip (phlegm seems to goes backward from your nose into your throat), then this may be the case. The mainstay of treatment is avoidance of the allergic trigger(s) (and these need special tests to be identified), an oral antihistamine, and intranasal steroid sprays.

B/ Regarding the headache and scalp tenderness you are describing, these fit into two possible diagnoses:

1- Muscle Contraction Headache
This is a type of headache caused by tension or sustained muscle contraction. The pain is usually described as a steady pain and other symptoms may include a sore scalp, nausea and blurred vision.
Tension headaches are very common; they occur when neck and scalp muscles become tense, or contract. The muscle contractions can result from stress, depression, a head injury, or anxiety.
Degenerative arthritis of the neck (degenerative changes in the neck vertebrae that occur with age; more common in elderly individuals), temporomandibular joint dysfunction (TMD: clicking and inflammation of the temporomandibular joint), or physical postures (Stooping or drooping of shoulders and neck, especially when using the computer; sitting with the droopy shoulders and a bent back) may trigger one of these headaches.
Any activity that causes the head to be held in one position for a prolonged time without moving can lead to headache. Such activities include typing or other computer work, fine work with the hands, and using a microscope. Sleeping in a cold room or sleeping with the neck in an abnormal position may also trigger a tension headache.
Other causes of tension headaches include:
• Alcohol use
• Caffeine (too much or withdrawal)
• Colds and the flu
• Eye strain
• Excessive smoking
• Fatigue
• Nasal congestion
• Overexertion
• Sinus infection
Tension headaches are described as follows:
• Dull, pressure-like
• A tight band around the head
• Involve the entire head (not just in one point or one side)
• Worse in the scalp, temples, or back of the neck
The pain may occur as an isolated event, constantly, or daily. Pain may last for 30 minutes to 7 days. It may be triggered by or get worse with stress, fatigue, noise, or glare. Difficulty sleeping is also reported. Unlike migraine headaches, tension headaches usually do not cause nausea or vomiting.
If you have headache that is mild to moderate, not associated with other symptoms, and responds to home treatment within a few hours, then no further examination or testing should be needed. The neurologic (nervous system) examination of an individual with a tension headache shows no abnormal findings. The most salient finding is that of tenderness in the muscles near the skull, which is often detected.
There are many different treatments for tension headaches. If these headaches become chronic, however, they are best treated by identifying the source of tension and stress and reducing or eliminating it.
Tension headaches usually respond very well to such over-the-counter analgesics as aspirin, ibuprofen, or acetaminophen. The downside is that some of these drugs (especially those that contain caffeine) may trigger rebound headaches if discontinued after they are taken for more than a few days.
More severe tension headaches may require combination medications, including a mild sedative such as butalbital; these should be used sparingly, though. Chronic tension headaches may respond to low-dose amitriptyline taken at night.
Massage and Physiotherapy
Massaging the tense muscle groups may help alleviate pain. Relief is best achieved by rubbing the neck and shoulders instead of directly massaging the temple, because tension headaches can arise from tension in this area. This kind of massage can reduce the intensity and duration of tension headaches by about 50%. To relax these muscles, the neck should be rotated from side to side as the shoulders shrug. Taking three very deep breaths at the first hint of tension can help prevent a headache.

Prevention is always important; it can be achieved by avoiding (as much as possible) stress and minimizing caffeine-containing medications. Managing everyday stress and lifestyle modifications are equally important in preventing tension headaches; these include:
• Taking frequent "stress breaks"
• Regular exercise
• Adequate refreshing sleep
• Release of stress and angry feelings

2- Nummular headache, previously known as coin-shaped headache (because it affects a coin-like zone in the scalp), is characterized by:
• a continuous or intermittent head pain that is exclusively felt in an area of the scalp that is usually 2-6 cm in diameter
• The affected area should be sharply contoured, fixed in size and shape, round or elliptical.
• Pain is mainly localized in the parietal region (above and slightly posterior to the ears)
• Exacerbation of pain is often observed.
• Other sensations in the affected area, such as paresthesia (numbness or tingling), are reported
• Mild to moderate head pain intensity
• Head pain is chronic and either continuous or interrupted by pain-free periods lasting weeks to months
• Symptoms are not explained by another medical condition

Nmmular headaches are slightly more common in females than in males. The size of the affected area as well as the shape, round or elliptical typically, does not alter with time. With the baseline pain, there may be flares of lancinating or stabbing pain that last for several seconds or gradually increases in duration over minutes to hours. During spontaneous remissions of the head pain, individuals may experience paresthesia, dysesthesia, which is an unusual, abnormal sensation, and/or tenderness in the area of pain. In about a third of cases, a doctor will be able to reproduce the tenderness when pressing on the area during a physical examination.

Diagnosis usually requires imaging of the brain, like a computed tomography scan (CT scan) or a magnetic resonance imaging (MRI) in order to ensure that there is no other cause for your headache, especially due to the rarity of nummular headaches.
The cause of nummular headaches is poorly understood. It is hypothesized that it results from a localized irritation or neuralgia of one of the branches of the trigeminal nerve, a nerve located in the facial area. An interesting observation is that individuals suffer from nummular headache also commonly suffer from migraines. Whether there is a link between the cause of migraines and nummular headaches is unknown.

Treatment relies on various medications including NSAID, gabapentin, an opiate, a tricyclic antidepressant, Tylenol, topiramate (Topamax), and carbamazepine. For people who fail to respond to classical medical therapy, botulinum toxin known by the trade name Botox, may be an option. Botulinum toxin is a toxin produced by the bacteria Clostridium botulinum and works by blocking nerve connections, which decreases muscle activity.

You need to initially consult an Ear-Nose-throat specialist to rule out any nose and sinus disease; if all proves normal, you will need to see a neurologist to make the correct diagnosis and devise the appropriate treatment plan.