Cold stimulus headache

INTRODUCTION — Cold stimulus headache, also known as ice-cream headache or brain-freeze headache, is triggered by exposure of the unprotected head to a cold environment or by ingesting cold materials that pass over the palate and posterior pharynx.

This topic will discuss cold stimulus headache. Other uncommon headache syndromes characterized by recurrent episodes of brief pain are reviewed separately.

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

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

●(See "Hypnic headache".)

●(See "Primary cough headache".)

●(See "Primary stabbing headache".)

Cranial neuralgias and central causes of facial pain are discussed elsewhere. (See "Overview of craniofacial pain" and "Central neuropathic facial pain" and "Nervus intermedius neuralgia" and "Nummular headache" and "Occipital neuralgia" and "Trigeminal neuralgia".)

PATHOPHYSIOLOGY — The pathophysiology of cold stimulus headache is not completely understood. Cold temperature seems to be a trigeminal trigger [1] that is followed by possible cerebrovascular changes [2]. In one study of 77 volunteers who ingested ice water, those who developed a cold stimulus headache had a higher mean flow velocity (MFV) in the middle cerebral arteries than those who did not [3]. The MFV was even higher when the headache was accompanied by lacrimation, which could suggest involvement of a trigeminal-parasympathetic vasodilator reflex in the pathophysiology of this disorder [3].

EPIDEMIOLOGY — The overall lifetime prevalence range is 15 to 37 percent, but in the pediatric population, the lifetime prevalence appears to be higher, ranging from 41 to 79 percent [4]. There does not appear to be gender predilection among children, but cold stimulus headache appears to be more common in adult females than in males [4]. Some [2,5-7], but not all [8,9], studies suggest that cold stimulus headache is more common among individuals with migraine than in the general population. A genetic predisposition is suggested by the results of a cross-sectional epidemiologic study of students (age 10 to 14 years) from Germany, which found that the risk of cold stimulus headache was increased for children whose mother (odds ratio [OR] 10.7) or father (OR 8.4) had cold stimulus headache [10].

CLINICAL MANIFESTATIONS — Cold stimulus headache is a generalized headache that follows exposure of the unprotected head to a cold environment, such as diving into cold water or receiving cryotherapy [11]. In addition, cold stimulus headache can be triggered by passing solid, liquid, or gaseous cold materials over the palate and posterior pharynx. Common examples include ingesting ice cream or crushed ice slurry.

After exposure to the cold stimulus, the pain begins within seconds, peaks over 20 to 60 seconds, and then subsides in approximately the same time [2]. In experimental provocation of cold stimulus headache, the ice water stimulus provoked headache significantly more often than the ice cube stimulus (51 versus 12 percent), and ice water-provoked headache had a shorter latency (median 15 versus 68 seconds) [12]. However, the pain can last up to five minutes in some patients [13]. The headache location is most commonly midfrontal, followed by bitemporal or occipital [2]. The character after ice cube stimulation has been described as predominantly pressing and after ice water stimulation as predominantly stabbing [12]. When cold stimulus headache occurs in patients with migraine, the pain is more likely to be throbbing [6] and referred to the usual site of the migraine headache [11].

DIAGNOSIS — The International Classification of Headache Disorders, 3^rd edition (ICHD-3), includes the following two subtypes of cold stimulus headache and requires that all of the following diagnostic criteria are present [11]:

●Headache attributed to external application of a cold stimulus:

•(A) At least two acute headache episodes fulfilling criteria B and C

•(B) Brought on by and occurring only during application of an external cold stimulus to the head

•(C) Resolving within 30 minutes after removal of the cold stimulus

•(D) Not better accounted for by another ICHD-3 diagnosis

●Headache attributed to ingestion or inhalation of a cold stimulus:

•(A) At least two episodes of acute frontal or temporal headache fulfilling criteria B and C

•(B) Brought on by and occurring immediately after a cold stimulus to the palate and/or posterior pharyngeal wall from ingestion of cold food or drink or inhalation of cold air

•(C) Resolving within 10 minutes after removal of the cold stimulus

•(D) Not better accounted for by another ICHD-3 diagnosis

MANAGEMENT — Cold stimulus headache is best prevented by avoiding the known stimulus [2]. There is no specific intervention for treatment, as the headache is generally short lived.

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: Neuropathic pain".)

SUMMARY AND RECOMMENDATIONS

●Terminology – Cold stimulus headache is also known as ice-cream headache or brain-freeze headache. (See 'Introduction' above.)

●Epidemiology – The prevalence of cold stimulus headache is up to 37 percent in the general population and may be more common among children and individuals with migraine. (See 'Epidemiology' above.)

●Causes and clinical features – Cold stimulus headache can be triggered by exposure of the unprotected head to a cold environment or by passing solid, liquid, or gaseous cold material over the palate and posterior pharynx. The pain begins within seconds after exposure to the cold stimulus, peaks over 20 to 60 seconds, and then subsides in approximately the same time. The headache location is usually bilateral but may be unilateral in those with comorbid migraine. (See 'Clinical manifestations' above and 'Diagnosis' above.)

●Prevention – Cold stimulus headache is best prevented by avoiding the known stimulus. (See 'Management' above.)