A woman in her fifties sat down in my clinic last spring and placed one fingertip on the right side of her head, just behind the crown. “It is always here,” she said. “Right here. About the size of a coin. It has been here for eight months, and three doctors have told me it is tension or nerves.” She had a normal MRI and a bag of painkillers that did very little. What she described has a name: nummular headache. If your pain sits in one small, round spot on the scalp and does not wander, this is the first diagnosis I consider, after I have made sure nothing dangerous is hiding underneath.
The short answer: nummular headache is a benign primary headache disorder in which pain is felt in a sharply defined, round or elliptical area, usually one to six centimetres across, with a fixed size and shape. It is uncommon, it is real, and it is often missed because the scalp spot looks too small and too local to be a “headache” at all.
What nummular headache feels like
“Nummular” comes from the Latin word for coin. Patients describe pressure, stabbing, or a dull, burning ache inside a circle they can outline with a finger. The key features I listen for are these: the area is the same shape and size from one attack to the next, the pain does not spread outward, and the patch is often most noticeable on the parietal region, the upper side of the head, though it can occur anywhere on the scalp.
Some people have constant background discomfort with short flares. Others have attacks lasting minutes to hours that come and go over weeks. The spot may feel tender to touch, and some patients notice altered sensation, such as tingling, numbness, or a hypersensitivity to brushing hair. Nausea, light sensitivity, and aura are not part of the picture. When they are present, I think about migraine instead.
What I rule out before I use this label
Nummular headache is a diagnosis I make with care, because a small fixed spot of scalp pain can also be a structural problem underneath it. The international classification itself says the pain must not be better explained by another condition. In practice that means examining the scalp and skull, and imaging when the story calls for it.
The causes I look for include a lesion of the skull bone or the tissues beneath the painful area, a skin or scalp condition such as shingles, a previous surgical or injury site, and nerve irritation from the small branches that supply the scalp. In people over fifty, a tender scalp spot with jaw pain or visual symptoms raises the question of giant cell arteritis, which is urgent; I explain that picture in my article on temporal arteritis. Pain at the back of the head with electric shocks points toward occipital neuralgia rather than a coin-shaped patch.
Many patients arrive already holding a normal scan and wondering why they still hurt. A normal MRI is reassuring, but it does not exclude a primary headache disorder; I wrote about what that scan can and cannot tell you in Normal MRI but Still Headaches?. When I suspect a nummular pattern, I ask the radiology team to look specifically at the painful spot, because a routine whole-brain study may not focus on the skull surface there.
Why it gets mislabelled
The most common wrong labels I see are tension-type headache, anxiety, and scalp “sensitivity.” Tension-type headache is usually a band or a diffuse pressure on both sides, not a precise coin on one spot. And because the pain is so local, patients are sometimes sent to dermatology, dentistry, or physiotherapy before anyone considers a nerve or headache disorder. If you have had a persistent one-sided headache that never quite fits, my overview of the one-sided headache that will not go away lists the other conditions worth comparing.
If you feel your headache has been explained away without a real examination, the pattern I describe in Headache Not Getting Better? What Doctors Miss may sound familiar.
What helps
The honest news is that evidence is limited, because the condition is rare and studies are small. Simple painkillers help some people only partly. Treatments with the best reported results in case series include topical agents applied to the spot, such as lidocaine or capsaicin, local nerve or tender-point injections, and preventive medicines used for neuropathic pain, including gabapentin. Botulinum toxin injected into the painful area has helped selected patients. I choose among these based on how disabling the pain is, whether the spot is constant or in attacks, and what other medicines the person already takes.
Two reassurances matter to my patients. First, nummular headache is not dangerous once a structural cause has been excluded. Second, in many people it eventually settles or fades on its own, although this can take months or years. I also advise against taking simple painkillers on most days, since frequent use can add a second problem, medication-overuse headache.
When a scalp spot needs prompt attention
See a doctor quickly if the spot is new and you are over fifty, if it comes with jaw pain on chewing, vision changes, or fever, if there is a visible lump, skin change, or rash, if it follows a head injury, or if you develop weakness, confusion, or seizures. A spot that grows, changes shape, or starts to spread is not behaving like nummular headache and needs a fresh evaluation.
Next steps
- Check yourself against my free headache red-flag checklist.
- If a fixed spot of pain has been dismissed or unexplained, you can talk to a specialist about an examination and a plan.
Dr. Tae-Ho Guak, MD, is a neurologist with more than 25 years of clinical experience. This article is for general education and is not a substitute for personal medical advice, diagnosis, or treatment. If you have a sudden severe headache or neurological symptoms, seek emergency care.
From the textbook. Chapter 35, “Primary Stabbing Headache and Nummular Headache,” of my clinical textbook Headache Medicine covers this topic in full for doctors, with the evidence and decision pathways behind it. About the book →