Incidence and influence on referral of primary stabbing headache in an outpatient headache clinic

Abstract

Primary stabbing headache (PSH) is a pain, as brief, sharp, jabbing stabs, predominantly felt in the first division of trigeminal nerve. Population studies have shown that PSH is a common headache. However, most people suffer attacks of low frequency or intensity and seldom seek for medical assistance. There are few clinic-based studies of PSH, and its real influence as a primary cause for referral to neurology outpatient offices is to be determined. We aim to investigate the burden of PSH as main complaint in an outpatient headache clinic. We reviewed all patients with PSH (ICHD-II criteria), attended in an outpatient headache clinic in a tertiary hospital during a 2.5-year period (January 2008-June 2010). We considered demographic and nosological characteristics and if PSH was main cause of submission. 36 patients (26 females, 10 males) out of 725 (5%) were diagnosed of PSH. Mean age at onset 34.1 ± 2.9 years (range 10-72). Mean time from onset to diagnosis 68.8 ± 18.3 months. Twenty-four patients fulfilled ICHD-II criteria for other headaches (14 migraine, 6 tension-type headache, 2 hemicrania continua, 1 primary cough headache and 1 primary exertional headache). 77.7% of patients were submitted from primary care. In 14 patients (39%), PSH was main reason for submission, its intensity or frequency in 5 (35.7%) and fear of malignancy in 9 (74.3%). Only two patients of those who associated other headaches were submitted due to PSH. In conclusion, PSH is not an uncommon diagnosis in an outpatient headache office. However, and according to our data, it is not usually the main cause of submission to a headache clinic.

Full text

ORIGINAL
Incidence and influence on referral of primary stabbing headache
in an outpatient headache clinic
A. L. Guerrero •S. Herrero •M. L. Pen
˜as •
E. Cortijo •E. Rojo •P. Mulero •R. Ferna
´ndez
Received: 7 October 2010 / Accepted: 18 December 2010 / Published online: 6 January 2011
ÓThe Author(s) 2011. This article is published with open access at Springerlink.com
Abstract Primary stabbing headache (PSH) is a pain, as
brief, sharp, jabbing stabs, predominantly felt in the first
division of trigeminal nerve. Population studies have shown
that PSH is a common headache. However, most people
suffer attacks of low frequency or intensity and seldom seek
for medical assistance. There are few clinic-based studies of
PSH, and its real influence as a primary cause for referral to
neurology outpatient offices is to be determined. We aim to
investigate the burden of PSH as main complaint in an out-
patient headache clinic. We reviewed all patients with PSH
(ICHD-II criteria), attended in an outpatient headache clinic
in a tertiary hospital during a 2.5-year period (January 2008–
June 2010). We considered demographic and nosological
characteristics and if PSH was main cause of submission.
36 patients (26 females, 10 males) out of 725 (5%) were
diagnosed of PSH. Mean age at onset 34.1 ±2.9 years
(range 10–72). Mean time from onset to diagnosis 68.8 ±
18.3 months. Twenty-four patients fulfilled ICHD-II criteria
for other headaches (14 migraine, 6 tension-type headache, 2
hemicrania continua, 1 primary cough headache and 1 pri-
mary exertional headache). 77.7% of patients were submit-
ted from primary care. In 14 patients (39%), PSH was main
reason for submission, its intensity or frequency in 5 (35.7%)
and fear of malignancy in 9 (74.3%). Only two patients of
those who associated other headaches were submitted due to
PSH. In conclusion, PSH is not an uncommon diagnosis in an
outpatient headache office. However, and according to our
data, it is not usually the main cause of submission to a
headache clinic.
Keywords Primary stabbing headache Headache clinic 
Primary care
Introduction
According to the International Classification of Headache
Disorders, second edition (ICHD-II) (Table 1)[1], primary
stabbing headache (PSH), is a head pain occurring as a
single stabs or series of stabs, exclusively or predominantly
felt in the distribution of the first division of trigeminal
nerve. Stabs are brief, lasting for up to a few seconds and
recurring with irregular frequency. To fulfill criteria, there
must be no accompanying symptoms or other disorder to
attribute pain. Jabbing pains are usually unilateral and
unifocal, but sometimes even multifocal and bilateral [2,3].
Despite mentioned criteria, other locations outside trigem-
inal region are possible, even in extracephalic region [4,5].
Population studies have shown that PSH is a common
headache [6]. However, most people suffer attacks of low
frequency or intensity and seldom seek for medical assis-
tance. There are few clinic-based studies of PSH, and its
real influence as a primary cause for referral to general
neurological or headache outpatient offices is to be deter-
mined. We aim to investigate the burden of PSH as main
complaint in an outpatient headache clinic.
Methods
We prospectively reviewed all patients with PSH diag-
nosed in accordance with ICHD-II criteria, attended in a
Partially presented as a Poster at the 20th Meeting of the European
Neurological Society, Berlin, June 2010.
A. L. Guerrero (&)S. Herrero M. L. Pen
˜as E. Cortijo 
E. Rojo P. Mulero R. Ferna
´ndez
Neurology Department, Hospital Clı
´nico Universitario,
Avda Ramo
´n y Cajal 3, 47005 Valladolid, Spain
e-mail: gueneurol@gmail.com
123
J Headache Pain (2011) 12:311–313
DOI 10.1007/s10194-010-0283-3

headache outpatient office in a tertiary hospital during a
2.5-year period (January 2008–June 2010). In each patient,
we considered demographic and nosological characteristics
and if PSH was the main cause of submission to our office.
In our Public Health Network, SACYL (Autonomous
Community of Castilla y Leon, Central Spain), patients are
referred to neurology outpatient offices by general practi-
tioners who act as gatekeeper, and they cannot self-refer to
neurology clinic. Besides, some patients were submitted
from general neurology offices or other specialities, mainly
neurosurgery.
Results
A total of 725 patients were attended in our headache clinic
during inclusion period. 36 (5%) of them (26 females, 10
males) were diagnosed of PSH accordingly to ICHD-II
criteria. Mean age at onset was 34.1 ±2.9 years (range
10–72) and did not differ between men and women. Mean
time from onset of symptoms to diagnosis was 68.8 ±
18.3 months.
Regarding headache profile, nature of pain was stabbing
in all patients. Jabs were bilateral in 28 cases (78%) and,
when unilateral, equally distributed between right and left
side (n=4, 11%). 16 patients (44%) felt pain paroxysms
in any region of the head. When jabs were restricted to a
fixed area, they were more frequently localized in frontal
area (n=12, 33%), followed by parietal (n=3, 8%),
occipital (n=3, 8%) and temporal (n=2, 5%).
Mean intensity of jabs, measured according to a visual
analogical scale (0 no pain, 10 the worst pain imaginable)
was 6.1 ±0.4 (range 3–8). 23 patients (64%) described
duration of a single jab under 5 s and 21 (58%) reported
more than a jab per day. Twenty-four patients (67%)
fulfilled ICHD-II criteria for other headaches. 14 of them
(12 females, 2 males) migraine with or without area, 6
(5 females, 1 male) tension type headache, 2 hemicrania
continua, 1 primary cough headache and 1 primary exer-
tional headache.
28 (77.7%) patients were referred to our headache clinic
from primary care, 2 (5.6%) from other neurology offices,
and 6 (16.7%) from other specialities, mainly neurosur-
gery. In only 14 patients (39%), PSH was the main reason
for headache clinic consultation and, among them, sub-
mission was due to frequency or intensity of stabs in 5
patients and to fear of malignancy in 9 cases. Only 2
patients among 24, who associated other headaches, were
referred due to PSH.
Regarding therapy, 10 patients received indomethacin
for PSH. Mean dose of indomethacin was 130 ±35 mg
and 20% patients had complete remission and 70%
partial response. In 13 patients, a preventative for the
comorbid headache (6 topiramate, 2 amitriptyline, 2
beta-blockers and 2 indomethacin) was prescribed; 30%
of them presented a complete remission and 70% a
partial response.
Discussion
Primary stabbing headache is a prevalent, but probably quite
unknown disorder, classified in ICHD-II as a primary
headache syndrome, with a female preponderance and onset
at middle age, as is found in our series [6–8]. Consistent with
the previous reports [1,7,9], our study shows that most
attacks last 5 s or less. In our series, most patients present
more than one stab per day. Accompanying symptoms
during attacks as allodynia, nausea/vomiting or photo-
phobia/phonophobia have been reported, mainly when
paroxysms are more intense [7,10].
Although fronto-ocular and temporal regions are the
most frequently affected [2,6], some reports have shown
that PSH can occur outside the trigeminal region, mainly
occipital or nuchal, and even in the extracephalic region
[4,5]. The attacks frequently change location from one
area to the next [4,7,9].
Regarding prevalence studies, existence of ultrashort
head pain paroxysms has been known for decades; initial
population-based studies showed an estimated prevalence
of around 2% [3,11,12]. However, as paroxysms are
usually associated with other headaches, it may be difficult
to estimate PSH real prevalence because the associated
headaches would receive more attention [3].
The large-scale study of headache epidemiology in
Vaga, Norway, carried out several years prior to ICHD
criteria, describes a prevalence of jabs suggestive of PSH
of 35% [4]. Most of the jabs described by Vaga parishio-
ners were mild, short-lasting and single; only 5% of
patients experienced more than five attacks per day [3,11].
Long-lasting jabs (\1% of described jabs in Vaga study)
seem to be associated with migraine [10].
Most people have attacks of low frequency, so perhaps
they seldom visit the doctor [3]. Patients admitted in out-
patient clinic might, so, be different from those surveyed in
Table 1 Diagnostic criteria of primary stabbing headache in ICHD-II
A Head pain occurring as a single stab or series of stabs and fulfilling
criteria B–D
B Exclusively or predominantly felt in the distribution of the first
division of the trigeminal nerve (orbit, temple and parietal area)
C Stabs last for up to a few seconds and recur with irregular
frequency ranging from one to many per day
D No accompanying symptoms
E Not attributed to another disorder
312 J Headache Pain (2011) 12:311–313
123

the community, but there are few large-scale clinic-based
studies of PSH [2,7].
Recently, two studies registering PSH patients according
to ICHD-II criteria in tertiary headache clinic have found a
quiet comparable frequency of this headache of 13% [7,8].
In these two studies is unclear whether patients contact
Hospital only due to PSH; besides, these patients com-
monly complain of other primary headaches, usually
migraines, probably the main cause of consultation. Mean
reasons of consultation described are severity of pain or
fear of stroke or malignancy.
Pharmacologic treatment is rarely necessary and usually
is prescribed due to a comorbid headache disorder as
occurs in our series. When the frequency of attacks is high,
indomethacin is the medication of choice [1,8,13]. Other
possibilities are melatonin, gabapentin and celecoxib and
even the botulinum neurotoxin with different results [14].
Conclusion
Although PSH is not uncommon in population or headache
clinic-based studies, it may be, according to our results, a
quite infrequent diagnosis in a headache outpatient office,
especially when considering primary cause of admitting.
Information about this treatable entity should be pro-
vided to population and/or primary care physicians.
Conflict of interest None.
Open Access This article is distributed under the terms of the
Creative Commons Attribution License which permits any use, dis-
tribution and reproduction in any medium, provided the original
author(s) and source are credited.
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