Creator: Dr. Hitesh Kumar
Published: 2016-09-01T04:56:11-04:00

Patient's Query

Hi doctor,

I am suffering from localized tenderness in scalp. I also have left thigh numbness. My doctor diagnosed it as mild meralgia paresthetica. He prescribed Pregabalin, but I did not take due to concern of dizziness and drowsiness. I always have a fear that antidepressant medicine can cause cancer in later stages of life. I have attached my medical history for your reference. Please help.

Answer

Dr. Hitesh Kumar

Neurology

Hello,

Welcome to icliniq.com.

Thanks for giving such an elaborate information and history (attachment removed to protect patient identity).

Scalp tenderness is a common symptom of migraine headache. It can be associated with hemicranial headache or it can be a sole symptom of migraine.

Though there are more other causes of scalp tenderness, in your case with a background history of migraine that seems to be the cause.

If migraine headache is very frequent, then it gets converted as chronic daily headache or in use frequent analgesics it can convert into medication overuse headache.

Pregabalin can cause some sedation. But, if started in low dosage and gradually increase, then sedation either does not occur or if occur lasts for three to five days only.

Gabapentin is a good alternative to Pregabalin, which cause very minimal sedation.

Left leg numbness can be meralgia paresthetica (numbness or pain in outer thigh due to nerve injury), but need investigations for that.

The Probable causes:

Poorly treated migraine or irregular treatment.

Investigations to be done:

1. Nerve conduction study of bilateral lower limbs, including bilateral lateral cutaneous nerve of thigh.
2. MRI brain and MR angiogram intracranial vessels with contrast.
3. ANA (antinuclear antibody), ESR (erythrocyte sedimentation rate), HBsAg (hepatitis B surface antigen), Anti HCV (hepatitis C virus), CRP (C-reactive protein) and fundus examination to look for papilledema.

Differential diagnosis:

1. Migraine headache leading to chronic daily headache.
2. Giant-cell arteritis (temporal arteritis).
3. Insomnia due to chronic daily headache.

Probable diagnosis:

Migraine headache.

Treatment plan:

Get nerve conduction study as advised above. If it suggests meralgia paresthetica, then try Gabapentin in place of Pregabalin.
Rule out other causes of scalp tenderness by MRI and blood tests. If the tests come out be normal, then start appropriate prophylactic medications for migraine.

Preventive measures:

1. Avoid trigger factors of migraine headache.
2. Do not wear tight belt at waist.

Regarding follow up:

Revert back with the test reports to a neurologist online.---> https://www.icliniq.com/ask-a-doctor-online/neurologist

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Patient's Query

Thank you doctor,

The MRI was done for scalp and brain before two years, which was quite normal. I do not have a headache. I have pain under the skin of the scalp. My glucose level in fasting and random are 75 and 105 respectively. My CRP, homocysteine and all other body function test like liver function, kidney, heart, TMT and echo are normal. My cholesterol is 200 and vitamin B12 is 180. I had only one episode of migraine before six years, which was a throbbing headache. Then, two years ago, I had left-sided dull continuous pain on the scalp that eases after rest or sleep, but comes again.

Answer

Dr. Hitesh Kumar

Neurology

Hi,

Welcome back to icliniq.com.

Many times, migraine are waxing and waning in nature. And the scalp tenderness and dull headache seems a type of migraine headache.

If the previous MRI brain was done with contrast, you can skip new MRI. But, if the previous one was without contrast, then I suggest you get another MRI brain with MR angiogram intracranial vessels with contrast.