Positional trigger of epicrania fugax may suggest a secondary headache: Report of four cases

Background Epicrania fugax is a brief paroxysmal severe stabbing pain that travels on scalp in a straight/zig-zag line. There are no known red-flags against primary epicrania fugax. Methods We identified four patients with secondary epicrania fugax characteristically triggered by head/neck movement. Results Four patients (age range 25–65 years, 2 females) with epicrania fugax were secondary to (a) acute subdural hematoma, (b) C1, C2 vertebral expansile metastasis (adenocarcinoma of prostrate), (c) type 1 Chiari malformation with cervical syrinx, and (d) pontine/cerebellar tuberculoma. All patients had severe pain (visual analog score 8–9/10) triggered by head/neck movement or on assuming upright posture. Patients with subdural hematoma and tuberculoma improved with dexamethasone. One with Chiari malformation showed partial response to gabapentin and patient with metastatic disease did not improve despite local radiotherapy, hormone treatment, gabapentin, dexamethasone and tapentadol. Conclusions Epicrania fugax triggered by head/neck movement should be evaluated for an underlying structural etiology.