Sometimes migraine patients will get sudden, severe, sharp headaches that feel like an ice pick stuck into their head. The International Classification of Headache (ICDH) calls this “Primary Stabbing Headache.”

This is an article by Britt Talley Daniel MD, retired member of the American Academy of Neurology, Migraine textbook author, Podcaster, YouTube video producer, and Blogger.

Read my mini book on Migraine-Click Here.

History of Primary Stabbing Headache, 

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%.  The pain is localized to a small point such as a needle or ice pick would make on the head and in the distribution of the trigeminal nerve.

Raskin [i}stated that, “Icepick-like pain appears to be a manifestation of migraine and should be distinguished from trigeminal neuralgia.”  The International Classification of Headache Disorders-3, ICHD-3, now calls this “Primary Stabbing Headache.”

Previously used terms

Ice-pick pains

jabs and jolts

needle-in-the-eye syndrome

ophthalmodynia periodica, Lansche [ii]

sharp short-lived head pain

Duration of attacks

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 repetively over days, and there has been one description of status lasting one week.

Location of attacks

Primary stabbing headache usually is pain occurring in the distribution of the trigeminal nerve-the forehead, maxillary cheeks or mandibular jaw.  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 and 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.

Other associated symptoms

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

Who gets primary stabbing headache?

Primary stabbing headache is commonly experienced by people with Migraine, and especially those with medication overuse headache leading to chronic migraine. In this situation the stabs tend to be localized to the site habitually affected by migraine headaches.  In some people, ice pick headaches can also cause nausea, vomiting, and dizziness.

What is the formal ICDH description?

ICDH 3 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.

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.

Stabbing headaches can be either:

“Primary,” meaning that the headache itself is the problem; or

“Secondary,” meaning that there is an underlying cause or condition responsible for the headache.

What other neurologic problems can imitate or be confused with Primary Stabbing Headache?

Trigeminal neuralgia.  An older, alternative name for this condition is “tic doloreaux” which is French for painful sharp, quick pain.  This is a headache type affecting older persons over 65 or occasionally young persons with multiple sclerosis.  The pain is solely in the distribution of the branches of the fifth cranial nerve, the trigeminal nerve, and usually in the second, maxillary division with pain at the corner of the mouth, the base of the nose, or the cheek. 

Trigeminal neuralgia can also less commonly occur in the upper forehead and lower jaw or mandibular division of the trigeminal nerve. 

The pains are described as lancinating, quick, like an electric shock, and lasting only a second or two.  There may be some residual lower level pain in the involved area of the face between the quick electric attacks.  Patients usually have a “trigger zone” which is a part of the face that when touched sets off the pain, usually located at the corner of the lips or in the cheek. 

Pain with this syndrome is set off by touch, wind breeze, eating, showering with water on face, and brushing the teeth.

The neurologic exam should be normal and MRI and MRA brain scans with contrast may be normal or show a small loop of an artery near the brain stem crossing over the trigeminal nerve at that location.  The pain is thought to be due to a “short circuit” in the nerve produced by the pulsatile artery.

Ninety percent of patients with trigeminal neuralgia are successfully treated with Tegretol or Trileptal.  Sometimes severe attack patients are treated by Gamma knife therapy, which is a focused radiation beam performed as an outpatient by a neurosurgeon.

Gamma knife therapy has a high success rate.  Rare patients are treated with an older neurosurgical procedure involving a back of the head craniotomy and insertion of a piece of gelfoam between the artery and the nerve.

SUNCT means short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing.  This syndrome consists of watery or red eyes, runny or stuffy nose, or swelling and flushing of the face and stabbing pains.

SUNA-short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms.

Cluster Headache which is defined by ICHD-3 as:

A. At least 5 attacks fulfilling B-D below.

B. Severe unilateral orbital, supraorbital, and/or temporal pain lasting 15 to 180 min.

C. Attack is associated with at least one of the following signs on the side of pain:

1. Conjunctival injection 

2. Lacrimation

3. Nasal congestion

4. Rhinorrhea

5. Forehead and facial sweating

6. Miosis

7. Ptosis

8. Eyelid edema

D. Frequency: from one every other day to eight per day

E. At least one of the following:

1. History, physical, and neurological examinations do not suggest disorders in groups 5-11 of IHS classification.

2. History and/or physical and/or neurological examinations do suggest other disorder, but it is ruled out by appropriate investigations.

3. Such disorder is present, but tension-type headache does not occur for the first time in close temporal relation to the disorder.

Cluster headache lasts longer (15-180) minutes while Primary Stabbing Headache is much shorter lasting only a few seconds.  This time duration separates the two headache syndromes quickly for clinicians.

Read my blog article on Cluster Headaches” on my website, www.doctormigraine.com.

Migraine.  This should be an easy diagnosis because Primary Stabbing headache is a quick, sharp, needle like pain, lasting 1-3 seconds, with maximum intensity of no pain to peak pain in a second.  The pain may come repeatedly in salvoes.  The anatomic distribution of the pain on the head, usually in the distribution of the trigeminal nerve is small, like a pin, a tiny well localized spot.

Migraine has a slow 1-2 hour buildup from onset to peak and is described as throbbing, pulsatile, and aching.  Galen first described the nature of what a migraine headache in the late 3rd century when he named it “hemicrania” in Latin, which means “half of head.”  As the years passed the “he” part of hemicrania was dropped and we have the word “micrania” which later became migraine. 

The most common symptom of migraine is that it is on one side of the head, present in 80%. 

So, migraine is not a sharp, needle, point pain, but a half of the head, spread out pain over a large distribution.  Also, migraine may have nausea and vomiting, disability, the need to be down, along with sensitivity to odors, light, and sound.

Check out my article on “What is Migraine?” on my website, www.doctormigraine.com

What is the neurologic workup for Primary Stabbing Headache?

People with new or never-evaluated stabbing headache should be carefully assessed by their doctor for an underlying cause.  Also, they should be evaluated to make sure that they do not have a different primary headache disorder that can mimic primary stabbing headache.

The neurologic exam, blood work including chemistries, CBC, and sed rate, CAT or MRI and MRA scans should be normal.

Treatment of Primary Stabbing Headache.

Usually, primary stabbing headache occurs a few times a day at most.  In rare cases they occur more frequently and may need treatment.

A problem with treatment is that the pain is so brief that it is gone before the person can even take medication.

In rare cases of Primary Stabbing Headache with frequent attacks will respond to Melatonin, available over the counter as a sedative.  For children a night-time dose of 1.5 mg has been successful and 10 mg at night may be used for adults.  There are few side effects with this.

Indomethacin at a daily dose of 25-75 mg/a day may be used with success, starting with a low dose of 25 mg and working up.  However, Indomethacin is an NSAID and had potential side effects of causing heartburn, nausea, gastroesophageal reflux, bleeding problems, medication overuse headache, and stomach ulcers.

For patients with secondary jab or stabbing headaches found in migraine patients who overtreat and develop medication overuse headache and chronic migraine.  The treatment is detoxing them off their offending pain killer, which is often caffeine, an NSAID, opioid drug, or butalbital, giving a week or two of prednisone, and using DHE nasal spray or IM injection for acute therapy till clearing.

In America and with certain insurance groups it is impossible to get DHE and so alternative drugs such as timolol eyedrops 0.5 % solution 2 drops at onset and then every 2 hours or olanzapine 2.5 or 5 mg at onset every 4-6 hours may be used until clearing of chronic migraine back to episodic migraine.

Read my article on “Medication Overuse Headache’ on my website, www.doctormigraine.com.

General headache warning.

A headache can be a warning sign for something more serious, such as a stroke or meningitis. People should always seek medical help if a headache develops after a blow to the head.

A severe headache requires immediate medical attention when it is accompanied by one of the following symptoms:

high fever

numbness

confusion

trouble seeing, speaking, or walking

Primary Stabbing Headache Summary

Primary stabbing headache is a rare uncommon headache disorder of short, stabbing, extremely intense headaches that last only seconds in duration and usually occur at most a few times per day.

Treatment is often not required due to the brief and infrequent nature of these headaches, but evaluation by a neurologist is suggested.

Literature Review of Primary Stabbing Headache.

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.”

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.

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

Resources:

The International Headache Society. https://www.ichd-3.org/other-primary-headache-disorders/4-7-primary-stabbing-headache/

Hagler S, Ballaban-Gil K, Robbins MS. Primary stabbing headache in adults and pediatrics: a review. Curr Pain Headache Rep 2014; 18:450

Fuh JL, Kuo KH, Wang SJ. Primary stabbing headache in a headache clinic. Cephalalgia 2007; 27:1005.

Rozen TD. Melatonin as treatment for idiopathic stabbing headache. Neurology 2003; 61:865

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.

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All the best.

Britt Talley Daniel MD