Primary stabbing headache – a narrative review

Abstract

Introduction
Primary stabbing headache (PSH), also known as “ice-pick headache”, is characterized by sudden, ultrashort stabs of head pain and may be under-recognized due to overlap with other headache disorders and mimics.
Objective
To provide a narrative overview of PSH, summarizing epidemiology, proposed mechanisms, clinical features, differential diagnosis, taxonomic evolution across ICHD editions, and reported treatments.
Methodology
A targeted search in PubMed/MEDLINE, SciELO and LILACS was complemented by manual reference screening, including key references cited in ICHD-3 (section 4.7). Keywords related to PSH were combined with “clinical presentation”, “epidemiology”, “diagnostic criteria” and “treatment”. Articles in English, Portuguese or Spanish were considered.
Results
Frequency estimates vary by definition and setting. Pediatric sources generally describe PSH as an uncommon diagnosis among children with recurrent headaches, with onset often during school-age years. In adults, estimates range from low values in population studies using stricter definitions to higher rates in community surveys eliciting ultrashort stabbing “jabs”. Attacks last seconds and occur as single jabs or brief series, with variable topography and laterality. Associated symptoms may reflect comorbidity (especially migraine); prominent cranial autonomic features should prompt reassessment for trigeminal autonomic cephalalgias or secondary causes when red flags are present. Evidence for treatment is largely uncontrolled; indomethacin is most frequently reported, while other agents appear in small series.
Conclusion
PSH is generally benign, but its reported frequency and phenotype are heterogeneous across studies. ICHD-3 broadened diagnostic inclusion beyond V1 distribution, potentially improving clinical fit. Careful differential diagnosis remains essential in atypical presentations.