Primary Stabbing Headache

Previously used terms:
Ice-pick pains; jabs and jolts; needle-in-the-eye syndrome; ophthalmodynia periodica; sharp short-lived head pain.

Description:
ICDH 3 Beta describes this as transient and localized stabs of pain in the head that occur spontaneously in the absence of organic disease of underlying structures or of the cranial nerves.

Comments:
Studies show 80% of stabs last three seconds or less; rarely, stabs last for 10-120 seconds. Attack frequency is generally low, with one or a few per day. In rare cases, stabs occur repetitively over days, and there has been one description of status lasting one week.

Primary stabbing headache involves extra-trigeminal regions in 70% of cases. It may move from one area to another, in either the same or the opposite hemicranium: in only one third of patients it has a fixed location. When stabs are strictly localized to one area, structural changes at this site and in the distribution of the affected cranial nerve must be excluded.

A few patients have accompanying symptoms, but not including cranial autonomic symptoms. The latter help to differentiate Primary stabbing headache from Short-lasting unilateral neuralgiform headache attacks (SUNCT).

Primary stabbing headache is commonly experienced by people with Migraine, especially with medication overuse headache and the stabs tend to be localized to the site habitually affected by migraine headaches.

This headache type has been called: icepick like pain (Raskin 1980)[i] headache, jabs and jolts, or ophalmodynia periodica (Lansche).[ii] 

Diagnostic criteria are:

A)  Head pain occurring as a single stab or a series of stabs and fulfilling criteria B-D.

B)  Each stab lasts for up to a few seconds

C)  Stabs recur with irregular frequency from one to many per day.

D)  No cranial autonomic symptoms.

E)  Not better attributed to another disorder.

Comments:
Studies show 80% of stabs last three seconds or less; rarely, stabs last for 10-120 seconds. Attack frequency is generally low, with one or a few per day. In rare cases, stabs occur repetitively over days, and there has been one description of status lasting one week.

Literature Review:

Raskin and Schwartz[iii] writing in Neurology in 1980 on “Icepick-like pain” studied the incidence and clinical characteristics of “sharp, jabbing pain about the head” in 100 migraineurs and 100 control subjects.  Three percent of controls and 4% of migraineurs described this syndrome.  The pain was “unifocal” at the temple or orbit and described as “icepick-like” by 52%.  Raskin stated that, “Icepick-like pain appears to be a manifestation of migraine and should be distinguished from trigeminal neuralgia.”

The patient with primary stabbing headache describes brief (1-3 seconds), of well-localized (usually pin point) jabs that “don’t last long enough to take anything to treat it.”  The pattern of the attacks varies and attacks may come 1-50 per day and have recurrences at irregular intervals of hours to days.  Autonomic symptoms are absent, unlike cluster headache and other trigeminal autonomic cephalalgias.  Reported triggers include physical exertion, bright lights, and head motion.[iv]  They hit the sufferer like the stabbings of a knife and the stabs may come singly or in salvoes lasting seconds.  They are usually unilateral, in the head, and in the distribution of the first branch of the trigeminal nerve (orbit, temple, and parietal) although reports of bilateral pain[v] and extra-trigeminal location[vi] are reported.

Pareja, et al,[vii] in 1996 writing on “Idiopathic stabbing headache (jabs and jolts syndrome)“ in Cephalalgia described the clinical features in 38 patients.  Mean age at onset of symptoms was 47 years with a female to male preponderance of 6.6 to 1.  Painful attacks were “ultrashort, i.e. virtually all attacks in more than two thirds of cases lasted only one second.”  A varying range of frequency from 1 attack per year to 50 attacks per day was found.  Localization of the pain was unilateral usually and located in the orbit, but patients with multiple pain sites were also seen.  Sometimes the attack location changed from one area to the next.  They found that Indomethacin treatment (75mg) had a “complete or partial effect in most patients treated.”

Jabs and jolts generally do not occur by themselves but do occur more often in migraineurs[viii],[ix] (about 40%) or cluster headache (about 30%) and in these patients the pain is felt in the usual site of the migraine or cluster pain.

Ammache, et al,[x] writing in Archives of Neurology in 2000 reported on a case of stabbing headache and monocular visual loss in a man with previous migraine with aura:

A 27-year-old man presented to the emergency department with stabbing, sharp pain in the right temporal area that was associated with nausea and complete loss of vision in his right eye.  He noted multiple episodes, each lasting a few seconds, which occurred during a 3-hour period.  Between episodes, the patient was free of headaches.  The loss of vision, which was only in his right eye, was described as a black disc with sparkles of light around the edge.  Visual loss and headache were precipitated by bright light.  There was no other neurologic deficit.  He had taken oral acetaminophen and diphenhydramine hydrochloride at home, without improvement.  His medical history since 1955 was remarkable for migraine with aura, which he described as a halo around objects lasting up to 30 minutes.  His family history revealed that his father also had migraine.  He was treated with oxygen (8 L/min) for 15 minutes, with resolution of his headache and loss of vision.  He was observed in the emergency department for 2 hours. During this time, he remained pain free and had no further visual episodes.  He was discharged on a 1-week regimen of Indomethacin sodium (25 mg three times a day), and over the next 10 months he experienced 3 recurrences of his ice pick headache, which occurred 3, 5, and 8 months after the initial episode.  The recurrences were milder in intensity and duration and were not associated with visual loss.  The first episode resolved spontaneously, and the other two were relieved by aspirin.

Treatment of primary stabbing headache

Franca, et al,[xi] 2004 reported on treatment response to Indomethacin failures with Gabapentin.  Fuh, et al,[xii] in 2007 reported their experience of primary stabbing headache in a headache clinic in Taiwan.  They reported on 80 patients and found Indomethacin was effective in 74%.  They reported that the head pain frequently involved extra trigeminal regions and that “70% of their patients could not fulfill criterion A ‘exclusively or predominantly in the distribution of the first division of the trigeminal nerve.”

Author’s comment:  ICDH 2 had for Diagnostic Criteria A) the requirement that the stabbing pain had to be in the distribution of either the right or left trigeminal nerve.  ICDH 3 Beta has dropped this requirement and the Franca, et al, article above was published in 2004 during ICHD 2.

Bibliography

[i] Raskin NH, Schwartz AB.  Icepick-like pain. Neurology.  1980;30:203.

[ii] Lansche RK. Ophtalmodynia periodica. Headache. 1964;4:247-249.

[iii] Raskin NH, Schwartz AB.  Icepick-like pain. Neurology.  1980;30:203.

[iv] Ammache Z, Graber M, Davis P.  Idiopathic Stabbing Headache Associated with Monocular Visual Loss.  Arch Neurol. 2000;57:745-746.

[v] Ibid.

[vi] Fuh JL, Kuo KH, Wang SJ.  Primary stabbing headache in a headache clinic.  Cephalalgia. 2007;27(9):1005-1009.

[vii] Pareja JA, Ruiz J, de Isla C, al-Sabbah H, Espejo J.  Idiopathic stabbing headache (jabs and jolts syndrome).  Cephalalgia. 1996;16(2):93-96.

[viii] Spierings ELH. Episodic Chronic Jabs and Jolts Syndrome.  Headache Quarterly, Current Treatment and Research. 1990;1(4): 299-302.

[ix] The International Classification of Headache, 2nd Edition. Primary stabbing headache. Cephalalgia 2004. 24;(Supplement 1):49-50.

[x] Ammache Z, Graber M, Davis P.  Idiopathic Stabbing Headache Associated with Monocular Visual Loss.  Arch Neurol. 2000;57:745-746.

[xi] França MC, Costa ALC, Maciel JA. Gabapentin-responsive idiopathic stabbing headache. Cephalalgia. 2004;24(11):993–996.

[xii] Fuh J-L, Kuo K-H, Wang S-J.  Primary stabbing headache in a headache clinic.  Cephalalgia.  2007; 27(9),1005–1009.