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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 14  |  Issue : 1  |  Page : 46-49

Chronic headache in a case of lipedematous scalp: Physiotherapy in symptom management


1 Department of Neurological Sciences, Ashok and Rita Patel Institute of Physiotherapy, CHARUSAT, Anand, Gujarat, India
2 Department of Musculoskeletal Sciences, Ashok and Rita Patel Institute of Physiotherapy, CHARUSAT, Anand, Gujarat, India

Date of Submission20-Jul-2019
Date of Decision08-Mar-2020
Date of Acceptance26-Mar-2020
Date of Web Publication29-Jun-2020

Correspondence Address:
Dr. Lourembam Surbala Devi
Department of Neurological Sciences, Ashok and Rita Patel Institute of Physiotherapy, CHARUSAT, Changa, Anand, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/PJIAP.PJIAP_18_19

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  Abstract 


Lipedematous scalp is a rare disorder of unknown etiology and pathogenesis. Since Cornbleet first described it in 1935, there have been better insights into the presentation, prognosis, and the treatment of the disease. The objective of this case report is to outline the physiotherapy findings and symptom management strategies as an adjunct to pharmacotherapy in a 52-year-old Indian female who presented with the complaints of chronic continuous headache and spongy scalp. She had no disorder other than hypertension. Chronic cervicogenic headache was diagnosed in our case with lipedematous scalp during physiotherapy examination for headache, which was the patient's primary complaint. Physiotherapy interventions in adjunct to pharmacotherapy had promising effects in reducing the severity of headache (NPRS score 8/10 to 1/10), neck stiffness and trapezius myalgia.

Keywords: Cervicogenic headache, chronic headache, lipedematous scalp, physiotherapy, spongy scalp


How to cite this article:
Devi LS, Dakoria D. Chronic headache in a case of lipedematous scalp: Physiotherapy in symptom management. Physiother - J Indian Assoc Physiother 2020;14:46-9

How to cite this URL:
Devi LS, Dakoria D. Chronic headache in a case of lipedematous scalp: Physiotherapy in symptom management. Physiother - J Indian Assoc Physiother [serial online] 2020 [cited 2020 Jul 6];14:46-9. Available from: http://www.pjiap.org/text.asp?2020/14/1/46/288358




  Introduction Top


Lipedematous scalp is a rare disease characterized by a localized accumulation of fatty tissue in the subcutaneous layer of the scalp, without hair loss. When associated with alopecia, it is known as lipedematous alopecia. Approximately 80 cases of lipedematous scalp with or without alopecia have been reported in the literature since its first report by Cornbleet in 1935.[1] The case is reported predominantly among the African-American women.[2] However, it has also been reported in Hispanics, Arabic, Turkish, Chinese, and Japanese. Lipedematous scalp may be associated with diabetes mellitus, hyperlipidemia, hypertension, and ovarian cysts. The clinical characteristics include an onset in the mid-50s, female predominance, and frequent involvement of the scalp vertex. Symptoms include diffuse pain, headache, burning, abnormal sensations (paresthesia), and thickening of the scalp with localized or generalized sensitivity of the scalp or itching (dysesthesia). Six cases have so far been reported on Indians; where chronic headache was one of the presenting features in two of the cases[3] and scalp dysesthesia in two other cases that was treated with antihistamines.[4] The characteristic finding is a gradual increase in scalp thickness, but the exact etiology is unknown. Most cases reported in the literature are focused on histopathological findings, MRI findings, and other biochemical and serological findings.[5] So far, physical examination and symptom management of chronic headache in LS has not been reported yet despite being the commonest presenting feature. The objective of this case report is to present the findings of physical examination and physiotherapy techniques in symptom management in adjunct to pharmacotherapy as presented in a 52 year old female with lipedematous scalp with the primary complaint of severe chronic headache.


  Case Report Top


A 52-year-old Indian Gujarati female presented to our outpatient physiotherapy department with the complaints of severe headache which was almost permanent, neck stiffness, and pain extending to the occiput. The headache was severe, which she scored 8/10 on Numerical Pain Rating scale (NPRS) and reported to have had the symptoms for 2 years, mostly diffused or present in the occipital region and sometimes radiating to the frontal region bilaterally. She managed her headache with over-the-counter medications and never consulted a physician earlier, to seek medical advice for her headache and other complaints. She denied any similar complains in the family. She was a known case of hypertension and was on antihypertensive medications for 5 years.

Initial observation of the patient revealed a forward stoop neck posture and a frowning forehead. Physical examination revealed features of cervicogenic dysfunction characterized by restriction in the cervical range of motion with symptoms worse in neck extension. Palpation of the neck region and cervical spine revealed a bilateral hyperactive upper trapezius muscle with associated myalgia, and hypomobility of the upper cervical spine. We measured the patient's baseline status using: Goniometric measurement for Cervical Range of Motion (CROM), Numerical Pain Rating Scale (NPRS) to quantify the severity of headache; and Pressure Algometry for Trapezius myalgia. We also used the Headache Disability Index (HDI) to examine the perceived impact of headaches on emotional functioning and daily activities. Our baseline examination revealed that the patient had severe headache (NPRS: 8/10), significant restriction of the CROM (CROM Extension: 0-52°; CROM Flexion: 0-46°; CROM Rotation – Right: 0-70°, Left: 0-65°), Trapezius myalgia on palpation (Pressure algometry - Left: 3.54 kg, Right: 3.06 kg) and affection of emotional functioning and majority of the daily activities (HDI Score: 64/100-severe disability). A diagnosis of cervicogenic headache was made based on the physical examination according to the Cervicogenic Headache International Study Group Diagnostic Criteria.[6] A soft spongy diffused bogginess and swelling of the occipital scalp region extending to the vertex was noted during palpation, which was associated with tenderness [Figure 1]. There was no visual evidence of scalp inflammation or difference in the density of hair in the occipital region. She reported the swelling to be gradual in onset and denied any history of pruritis, hair loss, head trauma, or any systemic problems. The spongy swelling of the scalp was clinically diagnosed as lipedematous scalp without alopecia by the dermatologist and prescribed medications; Pregabalin 75 Mg (P.O. Bid) and Tryptomer 10 Mg (h.s.) for 10 days. These medications have been proven effective in the management of neuropathic pain and migraine headaches, but its effectiveness in cervicogenic headache is yet unknown.[7] Routine investigation of complete blood cell counts (CBC), random blood sugar (RBS), lipid profile, and her neurological examination did not reveal any remarkable findings.
Figure 1: A remarkably thickened superficial tissue in the occipital region extending till the vertex

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Symptomatic physiotherapy management for chronic headache, neck pain and stiffness, and trapezius myalgia started on the day of examination as per the treatment recommendations by Biondi.[8] The physiotherapy management included the release of the hyperactive trapezius muscle and suboccipital muscles, Maitland mobilization of the upper cervical spine (C1-4), deep neck flexor strengthening, and transcutaneous electrical nerve stimulation in the nap of the neck and in the occipital region [Table 1]. The interventions were provided on a daily basis for six sessions and on alternate days in the subsequent days. At the end of the 12th session, the intensity of the headache reduced considerably which she scored 4/10 in the NPRS, along with decreased neck pain and stiffness. After the 12th session of supervised physiotherapy management, she was advised for home exercises which included isometric neck exercises and deep neck flexor strengthening and to follow up after one month. At follow up after 1 month, she had minimal complains of headache (0-1 in NPRS), neck stiffness or trapezius myalgia and reduced impact on daily activities (HDI Score – 24/100) [Table 2]. However, the bogginess and swelling of the scalp did not change significantly.
Table 1: Description of the physiotherapy interventions

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Table 2: Description of Outcome Measures

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  Discussion Top


Lipedematous scalp is an uncommon disease and and chronic headache is one of the most common manifestations of LS. Majority of the cases were reported in African-American women, but it may not be limited to a specific race. However, the role of female hormones could be related to the higher number of female patients. The diagnosis of lipedematous scalp is based on the physical findings of a spongy scalp and bogginess, which may or may not be associated with tenderness. So far, there is no report of a definitive treatment of lipedematous scalp or ways to arrest the progression of the disease and the treatment is mostly symptomatic. Corticosteroids and other medications have been reported to be used depending on the case. Oral mycophenolate mofetil, an immunosuppressive drug, was reported to have resulted in the successful treatment of a single case of lipedematous alopecia.[9]

However, the symptomatic management of chronic headache in LS has not been reported yet. This is the first case to report on the physiotherapy management strategies for chronic cervicogenic headache which was found to be coexistent in our case of LS. Studies that address the use and effects of medications for cervicogenic headache were limited. Where medications have been discussed, there has been the suggestion that cervicogenic headache is relatively unresponsive to most medications commonly used to treat other forms of headache. The use of physical means including cervical manipulation, transcutaneous electrical nerve stimulation and exercises were supported by a few randomized controlled trials and a number of case series addressing cervicogenic headache.[10]

This case was unique in its presentation with the coexisting cervicogenic dysfunction and cervicogenic headache, which is not previously described in this condition. Regardless of the features of lipedematous scalp, cervicogenic dysfunction is one of the most common causes of headache in middle-aged individuals. Based on the clinical presentations and physical findings, we believe that cervicogenic dysfunctions may coexist with LS and may be a contributing cause of chronic headache in individuals with lipedematous scalp, as described in this case. Hence, it is advisable to be screened for cervicogenic dysfunctions in patients with lipedematous scalp to recognize the coexisting presentation of other causes of headache that may not otherwise be identified. Further screening of cases with similar presentations is required to confirm this assumption. However, we wish to place it in the public domain and invite discussions and opinions.

Conclusion

Cervicogenic dysfunction may be a contributing cause of headache in individuals with lipedematous scalp. Patients with a primary complaint of headache in lipedematous scalp should be screened thoroughly to rule out coexisting cervicogenic dysfunctions, where physiotherapy interventions may be beneficial in the symptomatic management of chronic headache in lipedematous scalp.

Acknowledgment

We would like to thank our valuable patient for her consent and cooperation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cornbleet T. Cutis verticis gyrata? Lipoma? Arch Derm Syphilol 1935;32:688.  Back to cited text no. 1
    
2.
Martín JM, Monteagudo C, Montesinos E, Guijarro J, Llombart B, Jordá E. Lipedematous scalp and lipedematous alopecia: A clinical and histologic analysis of 3 cases. J Am Acad Dermatol 2005;52:152-6.  Back to cited text no. 2
    
3.
Sahu P, Sangal B, Dayal S, Kumar S. Lipedematous scalp with varied presentations: A case series of four patients. Indian Dermatol Online J 2019;10:571-3.   Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Peter CV, Jennifer A, Raychaudhury T, Chandrashekhar L, Merilyn S, Gowda S, et al. Lipedematous scalp. Indian J Dermatol Venereol Leprol 2014;80:270-2.  Back to cited text no. 4
    
5.
Carrasco-Zuber JE, Alvarez-Veliz S, Cataldo-Cerda K, Gonzalez-Bombardiere S. Lipedematous scalp: A case report and review of the current literature. J Dtsch Dermatol Ges 2016;14:418-21.  Back to cited text no. 5
    
6.
Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: Diagnostic criteria. The cervicogenic headache international study group. Headache 1998;38:442-5.  Back to cited text no. 6
    
7.
Pizzolato R, Villani V, Prosperini L, Ciuffoli A, Sette G. Efficacy and tolerability of pregabalin as preventive treatment for migraine: a 3-month follow-up study. J Headache Pain 2011;12:521-5.   Back to cited text no. 7
    
8.
Biondi DM. Cervicogenic headache: A review of diagnostic and treatment strategies. J Am Osteopath Assoc 2005;105:16S-22S.  Back to cited text no. 8
    
9.
Cabrera R, Larrondo J, Whittle C, Castro A, Gosch M. Successful treatment of lipedematous alopecia using mycophenolate mofetil. Acta Derm Venereol 2015;95:1011-2.  Back to cited text no. 9
    
10.
Haldeman S, Dagenais S. Cervicogenic headaches: a critical review. Spine J 2001;1:31-46.  Back to cited text no. 10
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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