• Johanna Barón-Sánchez, Álvaro Gutiérrez-Viedma, Marina Ruiz-Piñero, Alicia Pérez-Pérez, Ángel Luis Guerrero, and María L Cuadrado.
• Headache Unit, Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain.
• J Pain Res. 2017 Jan 1; 10: 1453-1456.

BackgroundThe first description of epicrania fugax (EF) reported brief painful paroxysms that start in posterior regions of the scalp and move forward to reach the ipsilateral forehead, eye, or nose. A backward variation, wherein pain stems from frontal areas and radiates to the posterior scalp, has also been acknowledged. We report four patients with features reminiscent of EF and the coexistence of forward and backward pain paroxysms.MethodsWe considered all patients attending the headache outpatient office at two tertiary hospitals from March 2008 to March 2016. We enrolled four patients with paroxysms fulfilling criteria for EF and a combination of forward and backward radiations.ResultsIn all cases, pain paroxysms moved both in forward and backward directions with either a zigzag (n=2) or linear (n=2) trajectory. Three patients presented two stemming points, in the occipital scalp and forehead (n=2) or in the parietal area and eye (n=1), whereas the fourth patient only had a stemming point located in the parietal region. Pain quality was mainly stabbing, and its intensity was moderate (n=1) or severe (n=3). The duration of the paroxysms was highly variable (3-30 seconds), and two patients reported autonomic symptoms.ConclusionThe clinical picture presented by our patients does not fit with other types of known headache or neuralgia syndromes; we propose it corresponds to a bidirectional variant of EF.

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