Symptoms of Ice Pick Headache
An ice-pick is a sharp implement a bar man uses to get ice from an ice-bucket.
The term "ice pick headache" is meant to convey the idea that this intense sudden pain is the sort of pain you think would occur if you were stabbed in the eye or head with an ice pick.
Other names for this headache include "ophthalmodynia periodica" - the term first used in the 1960's when ice-pick pains were first described.
The approved term from the International Headache Society Classification is "Primary Stabbing Headache".
The headache is notable for:
Being very, very brief a second or two only
One series asked people to estimate how long the pain lasted, and the majority said the intense pain lasted only one to three seconds.
Occurring out of the blue, no provocation such as cough or straining or exercise
Not being associated with nausea, intolerance of light, vomiting or watering of the eye
Can occur once every few days or dozens of times every day
Some people will experience "volleys" of pain e.g. a shower of sudden ice-picks over a few minutes then none for hours or days
My own patients often tell me that they will wince or clutch their head briefly when an ice pick headache pain occurs.
Some will even stumble, such is the shock of the pain.
A dramatic fall to the ground during an ice-pick pain is called a drop attack.
There are rare cases where someone may even fall to the ground (without blacking out) such is the intensity of the pain.
The pain is so short-lived ("ultra-short") that they do not usually believe anything serious is wrong, they just want an explanation.
Others, including their doctors, are genuinely concerned that something awful has happened such as a brain haemorrhage, and that is the reason they end up seeing a neurologist.
The pain is said to occur in or above the eye, but a recent survey of pain location found that the sharp pains occur outwith the classic area 70% of the time, and can even be experienced in the neck (Wang et al Cephalalgia 2007).
Are Ice-pick Headache Common?
Because of under-reporting to medical practitioners, it is difficult to know exactly how common these headaches are.
Some estimate a low prevalance of about 1% of the population.
A Scandinavian Survey (the Vaga Headache survey) specifically looked for ice pick symptoms. They reported that 35% of people may report "jabs" and "jolts" in the head from time to time.
They can occur at any age, and I know that teenagers and retired persons can all report this symptom.
What causes Ice Pick Headaches?
In almost every case, no cause for the headaches is found.
In practice, as soon as I hear the history of ice pick headache, I usually breathe a sigh of relief, knowing that I should be able to reassure my patient.
Some people will have numbness or altered sensation in the area above the eye.
You could suggest that the headache is in some way due to inflammation or entrapment of a sensory nerve within the scalp, such as the supra-orbital, auriculo-temporal or greater occipital nerve. This theory is not firmly established.
About 25% of people with ice-pick pains will have a history of migraine.
There are only a few cases published in medical journals of serious disease associated with ice pick pains.
There are two cases reported (ever) of a benign brain tumour called meningioma whose ice pick pains resolved after removal of the tumour (Mascellino 2001).
As ice-pick is so common, it is possible to conclude the co-existence of a benign brain tumor was a coincidence.
Do I need a brain scan if I have these severe headaches?
I will sometimes request a brain scan if the pains are provoked by exertion, but even then, with a characteristic history, normal neurological examination (that means your vision, strength and reflexes are OK) a scan is not essential.
You need to bear in mind that an MRI scan of brain has a 1 in 40 chance of an "incidental finding" i.e. it may show up something that is not relevant to your history and could not be predicted by knowledge of your clinical examination.
These "incidental findings" in themselves can cause even greater anxiety, or worse still, lead to further tests or procedures that could cause you harm.
Are there any treatments?
The first step is to explain the condition.
This should reassure the patient (and referring doctor) as often the sudden pain can make them think there has been a catastrophic event in the brain such as a subarachnoid haemorrhage.
Although unpleasant, ice pick pains are usually more of a nuisance than a disabling disorder.
In people with very frequent attacks of pain the following are usually recommended, but none are proven from randomised controlled trials:
Indomethacin 25 to 150mg daily
This is a very powerful anti-inflammatory medicine, and should not be used in someone with known ulceration of the stomach or duodenum. Asthma can also be exacerbated by use of this type of medication.
It should only ever be used on prescription by your doctor. The response to Indomethacin can be dramatic, although my own experience is perhaps more like a 50:50 response.
Gabapentin up to 1800mg per day
I will often use Gabapentin in conjunction with a course of Indomethacin for recurrent ice-pick pains. I usually give the Indomethacin for 5 or 7 days at a dose of 25mg three times daily, and start the Gabapentin at 300mg daily, increasing by 300mg per week till an effective dose or a max of 600mg three times daily.
The main problem with Gabapentin is that it can make you quite sleepy.
Melatonin 3mg at night
Melatonin is a naturally occurring hormone which regulates sleep. It has helped some people with difficult to control ice pick headache.