Scalp trichilemmal cysts and headache: a correlation with tension-type headache features in an adult female patient—a case report

Abstract

Introduction

Tension-type headaches (TTH) are prevalent primary headache disorders, affecting approximately 42% of the global population. Characterized by mild to moderate bilateral head pain, TTHs lack symptoms like photophobia and nausea (unless sometimes chronic TTH), distinguishing them from other headaches. They impose significant personal and societal burdens, particularly in high-income countries. Pathophysiology involves genetic factors, myofascial processes, and central sensitization. Gender disparities in healthcare further complicate diagnosis and treatment, often leading to misdiagnosis in women.

Case presentation

A 56-year-old Middle Eastern woman presented with a 10-month history of moderate occipital headaches, exacerbated by pressure. Initial misdiagnoses attributed her symptoms to psychological factors due to the patient’s gender, leading to inadequate treatment. A comprehensive neurological examination was conducted, revealing no neurological deficits but identifying two tender cysts on her scalp. Imaging studies confirmed subdermal and extracranial masses, diagnosed histologically as trichilemmal cysts. These findings suggested a potential link between the cysts and her headache symptoms.

Conclusion

While trichilemmal cysts are typically benign and asymptomatic, their presence on the scalp may contribute to bilateral discomfort with pain localized closer toward her trichilemmal cysts, exacerbating headache symptoms. This case highlights the importance of thorough physical examinations and consideration of atypical headache causes.

Introduction

Tension-type headaches (TTH) are among the most common headache disorders, affecting about 42% of the global population [1–3]. This headache disorder is characterized by recurrent episodes of mild to moderate-intensity pain in the head, with a tendency to occur bilaterally. The discomfort is frequently described as a ‘hatband’ pattern, although it may also localize to the forehead, posterior cervical regions, or occipital areas [1]. Notably, TTHs are devoid of accompanying symptoms such as photophobia, phonophobia, or nausea, distinguishing them from other forms of headache [4].

The pathophysiology of tension-type headaches involves multiple mechanisms, including genetic factors, myofascial processes, and central sensitization [1]. Genetic studies have suggested a hereditary component, with varying heritability estimates depending on the presence of migraine, and specific genes like the 5-HTTLPR polymorphism may influence the risk of developing TTH [5, 6].

Myofascial mechanisms, including muscle tenderness and the presence of myofascial trigger points, play a critical role. These trigger points, associated with hyperirritable muscle bands, can exacerbate pain in the head, neck, and shoulder regions, and contribute to peripheral and central sensitization [7]. Central factors include the sensitization of second-order neurons in the spinal cord and supraspinal structures, which may lead to the chronification of TTH, turning infrequent episodes into chronic tension-type headaches through central sensitization and impaired pain modulation [8]. While vascular factors, such as blood flow alterations have been observed, they are less central to TTH pathophysiology compared to conditions like migraine. These complex interactions between genetic predispositions, myofascial dysfunction, and central sensitization underline the multifactorial nature of TTH [1].

The International Classification of Headache Disorders (ICHD-3), a standard system used to diagnose headache and facial pain disorders, has clear definitions of such a disorder. The ICHD-3 classifies TTH as a primary headache disorder that is not caused by an underlying cause. On the other hand, if such an underlying cause is suspected, it is diagnosed as a secondary headache disorder. It also further divides it into infrequent, frequent, and chronic headache, with further subdivision based on the presence or absence of pericranial muscle tenderness [9]. According to our knowledge, there is no established evidence directly linking scalp trichilemmal cysts to the exacerbation of TTH.

Herein, we describe the clinical journey of an adult female patient presenting with a secondary TTH-like disorder, where potential gender bias may have led to an underestimation of her condition by healthcare providers. Our patient claims her symptoms were initially dismissed or misattributed, which is possibly influenced by prevailing stereotypes that tend to trivialize women's pain or attribute it to psychological factors.

Case presentation

A 56-year-old female patient of Middle Eastern descent came to the otorhinolaryngology clinic with a 10-month history of dull, moderate occipital headaches that are intermittent in nature. The patient reported bilateral tightening around the head, accompanied by symptoms similar to headband-like tension and pain, in addition to intensified, localized pain near to the two trichilemmal cysts.

Each episode lasted for about two hours. These headaches occurred both during day and night, and worsened when she puts pressure on her head, particularly when she wears a headscarf, pulls her hair up, or lays down on her back. The absence of other neurological symptoms, such as vomiting, fatigue, papilledema, and vision problems allowed us to rule out serious neurological issues. Her medical and surgical history were irrelevant. She did not complain of similar symptoms prior to the appearance of the cyst. The first visits to various physicians led to improper diagnosis and dismissals, including headaches induced by weather changes, sinusitis, allergies, psychological factors, or even menopause.

The patient expressed her concerns that her condition was being disregarded for no valid reason and she was not getting the right treatment, as her condition got worse. These assumptions led to symptomatic treatment without proper diagnostic workup, which made the patient’s condition worse and caused a dull, moderate and debilitating headache.

Upon presentation to our clinic, a full neurological exam was conducted. The patient was alert and aware, no signs of confusion or cognitive problems were present. There was no dysarthria or aphasia in her speech, which indicates a perfectly working cortical function. The cranial nerve exam was normal as well. There was no evidence of papilledema or other fundoscopic problems, visual field and acuity were normal, which rules out increased intracranial pressure and optic nerve pathology. The extraocular movements were full and there was no nystagmus, which means that neither the vestibular nor the central nervous system were involved.

The motor exam, which focused primarily on the upper and lower limbs, showed normal muscle tone and bulk, with full strength (5/5) in all major muscle groups. There were no involuntary movements or fasciculation. Regarding the sensory exam for light touch, pinprick, vibration and proprioception was normal as well, which rules out any signs of peripheral neuropathy and central sensory deficits.

Deep tendon reflexes were +2 and symmetrical on both sides, and there were no abnormal reflexes as Babinski sign or any other sign. Tests of coordination, like the finger-to-nose and heel-to-shin tests were performed smoothly, indicating intact cerebellum. The patient’s gait was normal, with the absence of signs of ataxia or imbalance. She was able to do tandem walking and the Romberg test without difficulty. Thus, cerebellar or vestibular dysfunctions were ruled out.

A thorough examination of the temporomandibular joint (TMJ) revealed no tenderness or issues, which indicates that TMJ-related headaches were unlikely. Palpation of temporal arteries showed no tenderness or problems, suggesting that giant cell arteritis is not affecting the temporal arteries. The neck examination was conducted, with full range of motion and no signs of musculoskeletal problems that could have contributed to the headache. In addition, the absence of nystagmus during the Dix–Hallpike maneuver ruled out an otoneurologic cause.

During scalp examination, a palpable mass was felt, upon removing her headscarf, two painful, red cysts were found in the parietal and occipital areas (Fig. 1). These findings indicated potential tension-type headache symptoms resulting from external pressure on the skull.

Fig. 1.

Gross photograph of a mass in the parietal region of the head. The white arrow and white dotted circle points out an erythematous, tender mass, which was found in the parietal region of the scalp. It measures about 0.5 cm × 0.5 cm. The patient’s pain was mainly centralized surrounding the cyst. A similar mass was found in the back of the head, particularly in the occipital region. We were unable to photograph it due to the patient’s hair covering the cyst

Computed Tomography (CT) scans were obtained, for further evaluation of the patient’s scalp masses. The imaging demonstrated two masses that were subdermal but extracranial, each one measuring about 0.5 cm × 0.5 cm in size, in the parietal and occipital regions (Fig. 2a, b). These findings confirmed the presence of localized masses without any involvement of the brain, ruling out the serious, invasive brain disease (Fig. 3a–c).

Fig. 2.

Sagittal computed tomography (CT) scan showing the cysts measuring 0.5 × 0.5 cm. a The arrow points to one of the cysts in the parietal area of the scalp; b the arrow points to one of the cysts in the occipital area of the scalp

Fig. 3.

Computed tomography (CT) scans of the head showing no apparent abnormalities. a coronal view of the head showing no evidence of sinusitis or other otoneurological abnormalities. b, c Transverse view of the head showing no intracranial abnormalities

Comprehensive laboratory tests were conducted to investigate potential systemic or metabolic factors could have been linked to the patient’s headache, which were inconclusive. The patient’s overall clinical image indicates that there are no hormonal, infectious or inflammatory processes that could exacerbate the headaches symptoms. The absence of such systemic issues made the diagnosis of tension-type headache-like symptoms linked by external pressure from extracranial cyst more likely. In addition, the patient had a histopathological analysis done at a different medical center, which has provided important information about the nature of the cyst. Excisional biopsy results reported trichilemmal cysts, characterized by a robust capsule composed of cuboidal, dark-staining basal epithelial cells organized in palisade arrangement. These cells coalesce with keratinocytes to form squamous epithelium, with dense eosinophilic-staining keratin present and absence of a granular cell layer.

The typical neurological examination findings were crucial to rule out various potential neurological issues for the patient’s headaches. The finding trichilemmal cysts as a possible cause of TTH-like symptoms, shows the importance of conducting a full detailed physical exam. The patient then was referred to a general surgeon for further evaluation and management of the cysts, which were likely the cause of her headache symptoms.

The patient came back 1 month later, after undergoing surgery, for a follow-up. She claimed to feel “back to normal” with minimal numbness around the site of surgery, specifically the scar area. There were no signs of pain, tension-type headaches, pressure muscle tension, or any other serious conditions.

The patient feels active with normal physical activity and claims to have a normal sleep schedule with a “peace of mind”.

All in all, it is worthy of noting that our report may come with certain limitations. The single-patient design, as well as the lack of controlling for confounders, and plausible placebo effects following surgery (lack of long-term follow-up), should be a call for more studies to investigate such a topic in a systemic manner.

Discussion

Trichilemmal cysts, also known as pilar cysts, are benign adnexal tumors originating from the outer root sheath of the hair follicle. These cysts are found on the scalp and are more common in middle-aged women. Although this disorder is rare, there is a potential for these cysts to become proliferative [10]. Trichilemmal cysts are primarily composed of soft tissue attenuation and may contain speckled calcifications and areas of high density due to cholesterol crystals and compact keratin [11]. These cysts are rare, non-cancerous, and usually painless. They are also known as wens and present on the face, neck, arms, and legs [12, 13]. According to our knowledge, the current literature lacks any reported evidence on the link between such cysts and TTH-like headaches.

Our patient’s neurological examination was normal and no focal neurological deficits were identified. Careful scalp inspection and imaging revealed multiple trichilemmal cysts. Other secondary headache etiologies including trigeminal or occipital neuralgia, dermatologic inflammatory conditions, and intracranial pathology were clinically excluded based on the symptoms pattern, physical examination, comprehensive laboratory tests, and imaging findings. The absence of paroxysmal lancinating pain or dermatomal distribution made neuralgias unlikely, while the absence of inflammatory skin changes argued against primary dermatologic pain syndromes. Collectively, these findings support the presence of secondary headache disorder with TTH like features, in the context of coexisting trichilemmal cysts.

Many differentials may come to mind when the patient complains of localized occipital pain, especially secondary causes, some of which are occipital neuralgia, a common cause of posterior scalp pain, cutaneous allodynia, which is pain triggered from light stimulation of the scalp and inflammatory dermatologic conditions. The absence of paroxysmal shooting pain, sensory disturbances or point tenderness in our case, rules out occipital neuralgia. In addition, upon further examination, the absence of skin inflammation and neuropathic hypersensitivity rules out cutaneous allodynia. This supports our diagnosis of extracranial compression from scalp cyst.

Although trichilemmal cysts themselves are not documented to be linked to the manifestation of TTH-like disorders, their presence might contribute to some localized discomfort or sometimes bilateral tension, potentially exacerbating TTH-like symptoms in some individuals. On the other hand, extracranial lesions such as cutaneous neuromas, lipomas, and other benign soft-tissue abnormalities have been reported to produce localized pain and/or referred headache through mechanisms such as local nerve compression, sustained pericranial muscle tension, or cutaneous allodynia. Dermatologic and surgical literature has documented improvement of headache or focal pain following the removal of the scalp lesions, supporting the concept that external compression or irritation may contribute to secondary headache syndromes with overlapping features of primary headaches [16–18]. In this context, the patient’s symptoms are more accurately classified as a secondary headache disorder with TTH-like features, rather than true primary TTH.

With regard to addressing gender disparities, the female patient reported that early consultations attributed her symptoms to psychological or menopausal causes and that diagnostic workup was delayed. We present these as patient‑reported experiences rather than proven provider intent. This pattern is consistent with recent analyses showing that women presenting with non‑specific pain complaints are less likely to receive standardized pain assessment and may wait longer for definitive evaluation and treatment. Broader reviews and position statements also document sex or gender biases in pain research and clinical practice, underscoring the need for clinicians to combine careful history, physical exam, and objective testing when women report persistent pain [15].

Women are more frequently affected by headaches, including migraines and TTH, compared to men. However, research and treatment strategies have historically been biased towards male subjects, leading to gaps in understanding and addressing female-specific headache issues. Women may experience different headache patterns and triggers as compared to men, influenced by hormonal fluctuations, stress, and other factors. Like what possibly happened to our patient, there is often a delay in diagnosis and treatment for women, potentially due to gender biases in medical research and practice [13, 14]. This disparity can result in inadequate management of headaches in women, affecting their quality of life and increasing the burden of disability associated with these conditions.

The relationship between these cysts and headaches warrants further investigation to better understand any potential interactions. Additionally, addressing gender disparities in diagnosing and treating headaches is crucial to improving outcomes for women. Increasing awareness and research focused on female-specific headache patterns and treatment responses are necessary to bridge these gaps and provide equitable healthcare for all individuals.

Conclusion

Our case highlights the complexity of diagnosing secondary TTH-like headache and the potential role of external factors, such as trichilemmal cysts, in exacerbating headache symptoms. While trichilemmal cysts are not reported to be associated with primary TTH, their location on the scalp in this patient suggests that they may contribute to bilateral discomfort with pain localized toward her trichilemmal cysts, potentially aggravating secondary headache symptoms that clinically resemble TTH.

Rather than establishing a casual relationship, this case underscores the importance of a thorough physical examination and comprehensive diagnostic workup in patients presenting with headache complaints that express typical patterns of TTH. Awareness of gender disparities in the diagnosis and management of headache disorders is important, as women are often subjected to misdiagnosis or delayed diagnosis, with symptoms sometimes attributed to psychological or hormonal factors rather than neurological causes. This case further highlights the need for heightened awareness of potential gender biases in healthcare and the importance of considering all contributing factors to a patient's condition to ensure timely and appropriate care.

Ultimately, this report emphasizes the necessity for individualized approaches to headache management and the need for continued research to better understand the multifactorial nature of TTH and the potential influences of coexisting conditions. Addressing gender disparities in both research and clinical practice remains critical to improving healthcare outcomes and ensuring equitable care for all patients suffering from headache disorders.

Abbreviations

TTH

Tension-type headache

TMJ

Temporomandibular joint

CT

Computed tomography

Author contributions

Y.A., S.H., H.Y., and Z.Y. partook in the writing of all sections of the case report. K.S. partook the final revision of the manuscript. K.N. gathered the patient’s data and partook in the writing of the case presentation. All authors read and approved the final manuscript.

Funding

None to declare.

Availability of data and materials

No datasets were generated or analyzed during the current study.

Declarations

Ethics approval and consent to participate

In Palestine, publishing of case reports does not have any official processes that one needs to undergo to get ethical approval by the research committee. According to practice, consent from patients is enough.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

None to declare.