Primary Stabbing Headache

1. Ade Wijaya, MD – December 2019

2. Outline:
 Introduction
 Epidemiology
 Diagnostic Criteria
 Pathophysiology
 Diagnostic Workups
 Differential Diagnosis
 Secondary Stabbing Headache
 Treatment
 Summary

3. Introduction
 First described by Lansche in 1964 as “ophthalmodynia periodica”
 Ice pick pains, jabs and jolts, needle-in-the-eye syndrome, and sharp
short-lived head pain.
“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.”
LanscheRK.Ophthalmodynia Periodica. Headache. 1964;4:247–9.
International Classification of Headache Disorders, Third Edition (ICHD-3)

4. Epidemiology
 Prevelence: 0.2 to 35%
 Female > Male
 Varied age of onset
Murray D, Dilli E. Primary Stabbing Headache. Current neurology and neuroscience reports. 2019 Jul 1;19(7):47.

5. Diagnostic Criteria
 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
International Classification of Headache Disorders, Third Edition (ICHD-3)

6. Diagnostic Criteria
For Probable Primary Stabbing Headache
A. Head pain occurring spontaneously as a single stab or series of stabs
B. Two only of the following:
 1. each stab lasts for up to a few seconds
 2. stabs recur with irregular frequency, from one to many per day
 3. no cranial autonomic symptoms
C. Not fulfilling ICHD-3 criteria for any other headache disorder
D. Not better accounted for by another ICHD-3 diagnosis
International Classification of Headache Disorders, Third Edition (ICHD-3)

7. Patophysiology
 Irritation of trigeminal and extratrigeminal nerves
 Intermittent impairment of central pain processing leading to hyper-
excitability of neurons or spontaneous synchronous discharge of
neurons
 Vascular mechanism
 Segmental disinhibition of central pain processing
Murray D, Dilli E. Primary Stabbing Headache. Current neurology and neuroscience reports. 2019 Jul 1;19(7):47.

8. Diagnostic Workups
 Rule out secondary causes
 Aware of red flags
 Brain CT/MRI
 Laboratory; ESR/CRP
Murray D, Dilli E. Primary Stabbing Headache. Current neurology and neuroscience reports. 2019 Jul 1;19(7):47.
Robbins MS, Evans RW. Primary and secondary stabbing headache. Headache: The Journal of Head and Face Pain. 2015 Apr;55(4):565-70.

9. Differential Diagnosis
 Secondary causes
 Trigeminal autonomic cephalalgias such as SUNCT, SUNA, paroxysmal
hemicrania, and hemicrania continua
 Primary cough headache, primary headache associated with sexual
activity, primary exertional headache, and cold stimulus headache
 Trigeminal neuralgia
Murray D, Dilli E. Primary Stabbing Headache. Current neurology and neuroscience reports. 2019 Jul 1;19(7):47.

10. Secondary Stabbing Headache
 Encephalitis
 Vasculitis
 Neoplasm
 Idiopathic Intracranial Hypertension
 Dural sinus stenosis
 Brainstem inflammation or focal demyelination
Robbins MS, Evans RW. Primary and secondary stabbing headache. Headache: The Journal of Head and Face Pain. 2015 Apr;55(4):565-70.
Murray D, Dilli E. Primary Stabbing Headache. Current neurology and neuroscience reports. 2019 Jul 1;19(7):47.

11. Treatment
 Indomethacin (75 to 250 mg/day in divided doses)
 Alternative treatments:
Selective COX-2 inhibitors, etoricoxib and celecoxib
Melatonin
Onabotulinumtoxin A (BoNTA)
Gabapentin
Topiramate
Acetazolamide
Nifedipine
Robbins MS, Evans RW. Primary and secondary stabbing headache. Headache: The Journal of Head and Face Pain. 2015 Apr;55(4):565-70.
Murray D, Dilli E. Primary Stabbing Headache. Current neurology and neuroscience reports. 2019 Jul 1;19(7):47.

12. Summary
 Stabbing pain without autonomic symptoms
 Benign
 Indomethacin (first line; if treatment needed)