Presentation and course
| |
• Most patients with primary stabbing headache have very brief attacks (less than 3 seconds). |
| |
• Patients with primary stabbing headache don’t have accompanying autonomic symptoms. |
| |
• The presentation of primary stabbing headache in children and adolescents varies widely and sometimes includes a family history. |
| |
• Patients, especially children, reported stab durations longer than a few seconds, which may indicate that ICHD-3 criteria need to be adjusted. |
Primary stabbing headache is characterized by brief, sharp, severe jabbing pains about the head that occur either as single episodes or as brief repeated volleys. The International Classification of Headache Disorders (ICHD) has formulated criteria for this diagnosis (Table 1) under the term 4.7 “primary stabbing headache” (11). The pain resembles a stab from an icepick, nail, or needle and typically lasts from a fraction of a second to 1 to 2 seconds. Primary stabbing headache may have the shortest duration of all known headaches. The frequency of attacks varies immensely, ranging from one attack per year to 50 attacks per day. The pain was originally believed to be isolated to the distribution of the trigeminal nerve; however, studies showed about 53% to 80% of patients with primary stabbing headache had stabs over extratrigeminal location (16), and the diagnostic criteria of ICHD-3 has removed this location requirement for diagnosis. Icepick-like pains are more common in women and do occur in children (01).
Table 1. ICHD-3 Diagnostic Criteria for Primary Stabbing Headache
| |
(A) Head pain occurring spontaneously as a single stab or a 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, ranging from one to many per day
(D) No cranial autonomic symptoms
(F) Not better accounted for by another ICHD-3 diagnosis |
Most stabs last 3 seconds or less; rarely, stabs last for 10 to 120 seconds (08). These pains are usually unilateral but may be bilateral. They occur mainly around the parietal region (44.4%), followed by the frontal region (21.5%) and occipital region (13.9%) (25). Attacks usually recur in the same area. If they occur in patients with other types of headache, they are characteristically located on the same side and frequently at the same site of the customary headache.
The attack frequency is generally low, with one or a few per day. Great variability exists in the temporal pattern of attacks. Most patients experience only single jabs, although some may have volleys of jabs. Attacks may be experienced as often as 50 times per day.
Approximately 38% to 74% of patients experience jolts, which are sudden movements that occur along with stabs (08; 14). In 18% of patients, vocalization has also been reported (08). Clinical-based studies have reported allodynia in 19% to 37% of patients (08; 18; 14). Accompanying phenomena, such as tearing, eye redness, or nausea, are absent.
A few patients, particularly those with comorbid migraine, have reported precipitating triggers for their idiopathic stabbing headaches. These triggers include rapid alterations in posture, physical exertion, bright light, and head motion during migraine attacks (23). In most patients, however, the pain is unprovoked.
Ammache and colleagues described a 27-year-old man with primary stabbing headache associated with monocular visual loss with scintillating scotoma ipsilateral to the pain (02). The patient had a history of migraine with aura.
Ahmed and colleagues reported on 42 children and adolescents with primary stabbing headache (01). Their mean age was 12 years. Most stabs were located in the extra-trigeminal regions. The frequency of the stabs ranged from daily to monthly. The presentation and nature of primary stabbing headache in children and adolescents vary widely. A family history of primary stabbing headache was identified in two patients in this cohort.
In another cohort of 77 children and adolescents with primary stabbing headaches, 16.9% were younger than 6 years of age at presentation (34). The location of the headache was frontal in 54.5% of patients and bilateral in 68.8%. A study showed that features of childhood primary stabbing headache can vary widely (21). Most of the stabs were between a few seconds and 30 minutes long, and more than half did not meet the ICHD-3 criteria of primary stabbing headache due to their duration. Additionally, this study found a high proportion of patients (33%) suffering from an associated primary headache, particularly migraines. Furthermore, 72% of patients had almost one episodic syndrome (infantile colic, benign paroxysmal vertigo, motion sickness, recurrent abdominal pain, and cyclic vomiting) (21).
Prognosis and complications
Primary stabbing headache is considered to be a benign condition, which may remit with time. In patients with infrequent attacks, education on the disorder may be sufficient, and medication may not be necessary. In patients on prophylactic treatments, periodic attempts to taper medication are reasonable to evaluate for possible remission.
It is hard to prognosticate about primary stabbing headache because of the great temporal variability. However, Kim and colleagues attempted to do so by prospectively screening and following patients diagnosed with primary stabbing headache in their clinic between June 2015 and March 2016 (14). They were able to identify 65 patients and found that most individuals followed one of three possible courses: a monophasic (n=31), intermittent (n=17), or chronic daily (n=12) pattern. Patients with a monophasic disease course tended to experience a duration of about 9 days, with attacks being of greater severity, occurring singly but with multiple attacks per day, side-locked attacks, and responding well to treatment. Patients with an intermittent pattern were more likely to be women and would experience symptoms on average for 2 years, with stabs being sporadic and of variable intensity. Chronic daily primary stabbing headache tended to last for 9 months, was more likely to occur in women, and presented with attacks that were longer-lasting and could change locations over the head. This study was the first to prospectively look at the clinical course of primary stabbing headache, and with the identification of three different typical patterns, hopefully, future research will help clarify etiology and help optimize treatment strategies.
Clinical vignette
Patient 1. A 64-year-old man started having headaches 5 years prior. The pain was usually felt over the left temporal region. It lasted less than a second and was described as a sharp pain, stabbing in nature. Other areas were also affected by the stabs, including the left and right parietal regions and the right occipital region. He had six to 12 stabs a day. No accompanying symptoms were associated with the pain. Physical and neurologic examinations were normal. MRI and MRA of the brain were also normal. The patient was put on indomethacin 25 mg, three times a day, with significant improvement in headache frequency; however, the medication was not well tolerated. Specific cyclooxygenase-2 inhibitors were then tried with good relief.
Patient 2. A 58-year-old woman started to complain of sudden pain in the right frontoparietal region for 3 weeks. The sudden stabs of pain, lasting about one minute, were very severe, always frightened the patient, and were followed by vocalization. She reported two to three episodes per day, without autonomic symptoms or any other manifestation in the beginning but the attacks increased progressively. Indomethacin 25 mg three times per day was started, but she still had frequent attacks. Celecoxib 100 mg twice daily was prescribed, but it was not effective. The brain MRA showed an aneurysm over right posterior communicating artery.
