Cold stimulus headache is defined as a short-lasting headache brought on by exposure of the head to cold temperatures or ingestion of cold substances. It is usually bilateral, frontal or temporal, and stabbing in quality, resolving within 10 minutes of removing the cold stimulus. The pathophysiology involves rapid constriction and dilation of cerebral blood vessels activating nociceptors, or sensory receptor activation through the trigeminal autonomic reflex. Treatment focuses on avoiding cold stimuli and slowly ingesting cold foods or drinks.

1. Cold Stimulus
Headache
Ade Wijaya, MD – April 2020

2. Outline:
• Definition
• Epidemiology
• Diagnostic Criteria
• Clinical Features
• Pathophysiology
• Treatment
• Summary

3. Definition
• Headache brought on by a cold stimulus applied externally to the
head or ingested or inhaled
• Includes headache following exposure of the unprotected head to a
very low environmental temperature, ice cream headache (ICH), also
known as “brain freeze,” and headache attributed to ingestion or
inhalation of a cold stimulus
• Headache attributed to ingestion or inhalation of cold stimulus is
defined as a short-lasting frontal or temporal pain that is possibly
intense and is induced in susceptible people by the passage of cold
material over the palate and/or posterior pharyngeal wall
Society HCCotIH. Headache Classification Committee of the International Headache Society (IHS) the international classification of headache disorders, 3rd edition. Cephalalgia. 2018;38(1):1–211.

4. Epidemiology
• The reported prevalence of cold stimulus headache is quite variable
• The lifetime prevalence of cold stimulus headache is reported to be 15%
• Children > adults
• More common in migraineurs compared to tension-type headache
(TTH) patients
• Family history may play a role in CSH
Chebini A, Dilli E. Cold Stimulus Headache. Current neurology and neuroscience reports. 2019 Jul 1;19(7):46.

5. Diagnostic Criteria
A. A single headache episode fulfilling criteria B and C
B. Brought on by and occurring only during or immediately after a cold
stimulus applied externally to the head or ingested or inhaled
C. Resolving within 10 min after removal of the cold stimulus
D. Not fulfilling ICHD-3 criteria for any other headache disorder
E. Not better accounted for by another ICHD-3 diagnosis
(2018) Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, 3rd edition. Cephalalgia, Vol.38(1)1–211.

6. Clinical Features
• Bilateral frontal or temporal headache
• Usually stabbing
• Short-lasting, ranging from a few seconds to a few minutes
Fuh JL, Wang SJ, Lu SR, Juang KD. Ice-cream headache–a large survey of 8359 adolescents. Cephalalgia. 2003;23(10):977–81.
Zierz AM, Mehl T, Kraya T, Wienke A, Zierz S. Ice cream headache in students and family history of headache: a cross-sectional epidemiological study. J Neurol. 2016;263(6):1106–10.
Hulihan J. Ice cream headache. BMJ (Clinical research ed). 1997;314(7091):1364.

7. Pathophysiology
1. Vascular Theory
• Palate and/or the posterior pharyngeal wall is exposed to a cold
substance  rapid constriction and dilation of vessels with activation
of nociceptors of the vessel wall
• Reduction in mean cerebral blood flow velocities of middle cerebral
arteries on transcranial Doppler ultrasonography has been reported in
patients who following cold stimulus developed a headache
2. Sensory Receptor Activation
Trigeminal autonomic reflex
Starling AJ. Unusual headache disorders. Continuum (Minneapolis, Minn). Headache. 2018;24(4):1192–208.
Hensel O, Mages S, Kraya T, Zierz S. FV 3 Functional transcranial Doppler (fTCD) during cold-induced pain in the oral cavity and ice cream headache. Clin Neurophysiol. 2017;128(10):e306–e7
Mages S, Hensel O, Zierz AM, Kraya T, Zierz S. Experimental provocation of 'ice-cream headache' by ice cubes and ice water. Cephalalgia. 2017;37(5):464–9

8. Treatment
• Avoiding the triggering factors
• Slow ingestion
• Mechanostimulus
Burkhart CG, Burkhart CN. Ice cream headaches with cryotherapy of actinic keratoses. Int J Dermatol. 2006;45(9):1116–7.
Starling AJ. Unusual headache disorders. Continuum (Minneapolis, Minn). Headache. 2018;24(4):1192–208.

9. Summary
• Headache brought on by a cold stimulus applied externally to the
head or ingested or inhaled
• Short-lasting, stabbing, bilateral frontal or temporal headache
• Vascular and trigeminal autonomic reflex theory
• Treatment: avoid the stimulus, slowing ingestion

10. THANK YOU