Primary stabbing headache

INTRODUCTION — Stabbing headache is an uncommon headache syndrome characterized by very brief stabs of recurring focal head pain. Primary stabbing headache has also been called:

●Idiopathic stabbing headache

●Ice-pick headache

●Ophthalmodynia periodica

●Jabs and jolts syndrome

This topic will discuss primary stabbing headache. Other uncommon headache syndromes characterized by recurrent episodes of brief pain are discussed separately.

●(See "Overview of thunderclap headache".)

●(See "Exercise (exertional) headache".)

●(See "Primary headache associated with sexual activity".)

●(See "Primary cough headache".)

●(See "Cold stimulus headache".)

●(See "Hypnic headache".)

The trigeminal autonomic cephalgias are similar headache syndromes also associated with cranial autonomic symptoms and are discussed separately. (See "Cluster headache: Epidemiology, clinical features, and diagnosis" and "Paroxysmal hemicrania: Clinical features and diagnosis" and "Short-lasting unilateral neuralgiform headache attacks: Clinical features and diagnosis" and "Hemicrania continua".)

PATHOPHYSIOLOGY — The pathophysiology of primary stabbing headache is not understood. Most patients also have another coexisting primary headache disorder, such as migraine or cluster headache [1]. In those cases, the stabbing usually occurs in areas of the head similar to the coexisting headache. This implies that the stabbing pain might result from spontaneous firing in individual nerve fibers sensitized by recurrent activation.

EPIDEMIOLOGY — The lifetime prevalence of primary stabbing headache may be up to 2 percent [2]. The female to male ratio is 1.5 to 1 [3]. Primary stabbing headache has been described in both children and adults [4,5].

CLINICAL FEATURES — Primary stabbing headache is characterized by transient, sharp, jabbing head pains that may cause the patient to wince [5]. Symptoms appear suddenly either as single stabs or in volleys of mild to intense stabbing pain [5].

●Duration and frequency – The individual stabs typically last for a few seconds but may be longer [1,6-8]. One study of 23 children reported that the stabs ranged from 1 to 15 minutes in duration [9].

Stabs occur at irregular intervals ranging from rare attacks to more than one each day [1,8]. Frequently recurring stabs may also occur in clustered episodes followed by a pain-free period of weeks to months [10]. In a study of 65 patients with primary stabbing headache, 72 percent of patients reported daily symptoms, and the frequency of daily stabs ranged from 2 to 30 in 55 percent, 30 to 100 in 17 percent, and >100 in 12 percent [10]. In one report of "ice-pick status," minute-long stabs recurred as a prolonged attack lasting one week [6].

●Location – The pain occurs anywhere in the head, typically in extratrigeminal regions [11]. In case series of children and adolescents with primary stabbing headache, frontal and parietal regions predominated [7,8]. In one series of 77 children, nearly 70 percent reported bilateral symptoms [8].

Patients may report exclusively unilateral symptoms. However, a structural abnormality must be excluded if the pain is invariably localized at one site or is side-locked. (See 'Differential diagnosis' below.)

●Associated symptoms – A minority of patients with primary stabbing headache may report nausea, vomiting, and/or photophobia associated with head pains [12]. Primary stabbing headache is not associated with cranial autonomic symptoms [13].

DIAGNOSIS — Primary stabbing headache should be considered in a patient with unprovoked, recurrent brief stabs of head pain. The diagnosis is made in patients whose symptoms fulfill diagnostic criteria when alternative causes have been excluded.

Diagnostic criteria — Diagnostic criteria for primary stabbing headache by the International Classification of Headache Disorders, 3^rd edition (ICHD-3) include all of the following [13]:

●(A) Head pain occurring spontaneously as a single stab or series of stabs and fulfilling criteria B and C

●(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 accounted for by another ICHD-3 diagnosis

When only two of the three headache features (criteria B through D) are met, patients are classified as having probable primary stabbing headache.

Diagnostic testing — We suggest diagnostic testing to exclude secondary structural causes for patients with strictly unilateral or atypical symptoms and in patients with symptoms that progressively worsen. (See 'Differential diagnosis' below.)

●Neuroimaging – We perform magnetic resonance imaging (MRI) of the brain with contrast if available. Computed tomography (CT) of the head may be performed as a less sensitive alternative study.

●Laboratory studies – We suggest obtaining an erythrocyte sedimentation rate and C-reactive protein to evaluate for inflammatory causes including giant cell arteritis in patients age >50 years.

We reserve vascular imaging and additional laboratory testing for patients with abnormal initial testing and in those with suspected alternative diagnoses. (See 'Differential diagnosis' below.)

Differential diagnosis — Symptoms consistent with primary stabbing headache may also be due to conditions such as giant cell arteritis or a traumatic injury to the scalp [14]. In addition, some patients may be found to have a structural abnormality on imaging such as a meningioma, pituitary adenoma, cavernous hemangioma, or stroke [1,15-17]. Secondary causes of stabbing headache are typically identified or excluded by imaging and other diagnostic testing. (See 'Diagnostic testing' above.)

The differential diagnosis of primary stabbing headache also includes other primary headache syndromes or cranial neuralgias that produce recurrent episodes of brief and/or focal head pain. Some conditions may be distinguished by clinical features:

●Trigeminal autonomic cephalgias (TACs) are a group of unilateral headache disorders associated with ipsilateral cranial autonomic symptoms, such as ptosis, miosis, conjunctival injection, and/or nasal congestion. The temporal patterns and treatments vary among TAC subtypes. Those characterized by brief, recurrent attacks include:

•Cluster headache (see "Cluster headache: Epidemiology, clinical features, and diagnosis")

•Paroxysmal hemicrania (see "Paroxysmal hemicrania: Clinical features and diagnosis")

•Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) (see "Short-lasting unilateral neuralgiform headache attacks: Clinical features and diagnosis")

•Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) (see "Short-lasting unilateral neuralgiform headache attacks: Clinical features and diagnosis")

●Occipital neuralgia may present with recurrent stabs of focal pain, but patients may report chronic baseline pain, and symptoms are typically restricted to the region of the scalp supplied by the occipital nerve. (See "Occipital neuralgia".)

●Cervicogenic headache features unilateral, occipital head pain that may vacillate in intensity with neck movement, but it is also typically associated with restricted range of motion and pain involving the neck or shoulder. (See "Cervicogenic headache".)

●Trigeminal neuralgia is a facial pain rather than headache syndrome. It is characterized by stereotyped, often stimulus-triggered attacks of stabbing pain within the distribution of the trigeminal nerve. (See "Trigeminal neuralgia".)

●Nummular headache is an uncommon headache syndrome characterized by a small, circumscribed area of continuous head pain. (See "Nummular headache".)

Other primary headache syndromes may be distinguished from primary stabbing headache by triggering circumstances. These include:

●Exercise-induced headache (see "Exercise (exertional) headache")

●Primary headache associated with sexual activity (see "Primary headache associated with sexual activity")

●Cough-induced headache (see "Primary cough headache")

●Cold stimulus headache (see "Cold stimulus headache")

●Hypnic headache (see "Hypnic headache")

TREATMENT — Patients with infrequent attacks may not desire treatment and may be monitored clinically. For other patients with primary stabbing headache who have frequent attacks or severe pain, we suggest indomethacin (75 to 150 mg daily) for initial therapy based on clinical experience. In case series, indomethacin was reported to be effective in 58 to 75 percent of patients with primary stabbing headache [11,18]. Melatonin (3 to 12 mg daily) is a reasonable alternative for patients unresponsive or intolerant to indomethacin, also reported to be effective in case reports and series [19-22]. No therapies have been evaluated in controlled trials. Other medications used for patients with primary stabbing headache include prednisolone, celecoxib, gabapentin, and tricyclic antidepressant medications [10,11].

Preventive treatment is typically weaned when symptoms resolve, typically after one to two months, to assess for spontaneous resolution of symptoms. Treatment may be resumed if symptoms recur.

PROGNOSIS — The prognosis of primary stabbing headache is not well established. Some patients may have a monophasic course resolving spontaneously or with treatment after several weeks, while others with relapsing attacks may report intermittent symptoms persisting for months or years [10].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Migraine and other primary headache disorders".)

SUMMARY AND RECOMMENDATIONS

●Clinical features – Primary stabbing headache is characterized by transient, sharp, jabbing head pains that may cause the patient to wince. Symptoms appear suddenly either as single stabs or in volleys of mild to intense stabbing pain that typically last for a few seconds. Stabs occur at irregular intervals ranging from rare attacks to more than one each day. (See 'Clinical features' above.)

●Diagnosis – The diagnosis of primary stabbing headache is made in patients whose symptoms fulfill diagnostic criteria when alternative causes have been excluded. (See 'Diagnosis' above.)

•Diagnostic testing – We suggest neuroimaging and limited laboratory testing to exclude secondary structural causes for patients with strictly unilateral or atypical symptoms and in patients with symptoms that progressively worsen. (See 'Diagnostic testing' above.)

•Differential diagnosis – The differential diagnosis of primary stabbing headache includes other headache syndromes that produce recurrent episodes of brief and focal head pain. Secondary causes of stabbing headache including brain tumors, vascular abnormalities, and giant cell arteritis are typically identified or excluded by imaging and other diagnostic testing. (See 'Differential diagnosis' above.)

●Treatment options – For patients with frequent attacks or severe pain, we suggest initial therapy for primary stabbing headache with indomethacin (75 to 150 mg daily) (Grade 2C). Alternative options include melatonin, prednisolone, celecoxib, gabapentin, or tricyclic antidepressant medications. Patients with infrequent attacks may not desire treatment and may be monitored clinically. (See 'Treatment' above.)