Ice Pick Headache
Atlas of Uncommon Pain Syndromes, Chapter 1, 1-2
ICD-9 CODE 784.0
ICD-10 CODE R51
The Clinical Syndrome
Ice pick headache is a constellation of symptoms consisting of paroxysms of stabbing jabs and jolts that occur primarily in the first division of the trigeminal nerve. These paroxysms of pain may occur as a single jab or a series of jabs that last for a fraction of a second followed by relatively pain-free episodes. The pain of ice pick headache occurs in irregular intervals of hours to days. Similar to cluster headache, ice pick headache is an episodic disorder that is characterized by “clusters” of painful attacks followed by pain-free periods. Episodes of ice pick headache usually occur on the same side, but in rare patients, the pain may move to the same anatomical region on the contralateral side. Ice pick headache occurs more commonly in women and is generally not seen before the fourth decade of life, but rare reports of children suffering from ice pick headache sporadically appear in the literature. Synonyms for ice pick headache include jabs and jolts headache and idiopathic stabbing headache.
Signs and Symptoms
A patient suffering from ice pick headache complains of jolts or jabs of pain in the orbit, temple, or parietal region ( Figure 1-1 ). Some patients describe the pain of ice pick headache as a sudden smack or slap on the side of the head. Similar to patients suffering from trigeminal neuralgia, a patient suffering from ice pick headache may exhibit involuntary muscle spasms of the affected area in response to the paroxysms of pain. In contrast to trigeminal neuralgia, involving the first division of the trigeminal nerve, there are no trigger areas that induce the pain of ice pick headache. The neurological examination of a patient suffering from ice pick headache is normal. Some patients exhibit anxiety and depression because the intensity of pain associated with ice pick headache leads many patients to believe they have a brain tumor.
Ice pick headache is characterized by jabs or jolts in the orbit, temple, or parietal region.
Testing
Magnetic resonance imaging (MRI) of the brain provides the best information regarding the cranial vault and its contents. MRI is highly accurate and helps identify abnormalities that may put the patient at risk for neurological disasters secondary to intracranial and brainstem pathological conditions, including tumors and demyelinating disease ( Figure 1-2 ). Magnetic resonance angiography (MRA) also may be useful in helping identify aneurysms, which may be responsible for the patient’s neurological findings. In patients who cannot undergo MRI, such as a patient with a pacemaker, computed tomography (CT) is a reasonable second choice. Radionuclide bone scanning and plain radiography are indicated if fracture or bony abnormality, such as metastatic disease, is considered in the differential diagnosis.
Diffuse pachymeningeal and calvarial metastasis from carcinoma of the breast. Axial T1-weighted postgadolinium MRI shows diffuse nodular and bandlike contrast-enhanced thickening of the dura over the high right frontoparietal convexity.
(From Haaga JR, Lanzieri CF, Gilkeson RC, editors: CT and MR imaging of the whole body, 4th ed, Philadelphia, 2003, Mosby, p 198.)
Screening laboratory tests consisting of complete blood cell count, erythrocyte sedimentation rate, and automated blood chemistry should be performed if the diagnosis of ice pick headache is in question. Intraocular pressure should be measured if glaucoma is suspected.
Differential Diagnosis
Ice pick headache is a clinical diagnosis supported by a combination of clinical history, normal physical examination, radiography, and MRI. Pain syndromes that may mimic ice pick headache include trigeminal neuralgia involving the first division of the trigeminal nerve, demyelinating disease, and chronic paroxysmal hemicrania. Trigeminal neuralgia involving the first division of the trigeminal nerve is uncommon and is characterized by trigger areas and tic-like movements. Demyelinating disease is generally associated with other neurological findings, including optic neuritis and other motor and sensory abnormalities. The pain of chronic paroxysmal hemicrania lasts much longer than the pain of ice pick headache and is associated with redness and watering of the ipsilateral eye.
Treatment
Ice pick headache uniformly responds to treatment with indomethacin. Failure to respond to indomethacin puts the diagnosis of ice pick headache in question. A starting dosage of 25 mg daily for 2 days and titrating to 25 mg three times per day is a reasonable treatment approach. This dose may be carefully increased to 150 mg per day. Indomethacin must be used carefully, if at all, in patients with peptic ulcer disease or impaired renal function. Anecdotal reports of a positive response to cyclooxygenase-2 (COX-2) inhibitors in the treatment of ice pick headache have been noted in the headache literature. Underlying sleep disturbance and depression are best treated with a tricyclic antidepressant compound, such as nortriptyline, which can be started at a single bedtime dose of 25 mg.
Complications and Pitfalls
Failure to correctly diagnose ice pick headache may put the patient at risk if intracranial pathological conditions or demyelinating disease, which may mimic the clinical presentation of chronic paroxysmal hemicrania, is overlooked. MRI is indicated in all patients thought to be suffering from ice pick headache. Failure to diagnose glaucoma, which also may cause intermittent ocular pain, may result in permanent loss of sight.
CLINICAL PEARLS
The diagnosis of ice pick headache is made by obtaining a thorough, targeted headache history. Patients suffering from ice pick headache should have a normal neurological examination. If the results of the neurological examination are abnormal, the diagnosis of ice pick headache should be discarded and a careful search for the cause of the neurological findings should be undertaken.
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