FFS: Primary Stabbing (Ice Pick)

Pains may occur in both trigeminal and extra-trigeminal regions, helping to distinguish it from trigeminal neuralgia.

Imaging is necessary to exclude structural abnormalities, especially if symptoms are consistently unilateral or localised to one site.

Most cases are brief and infrequent, and do not require treatment.

Persistent cases may respond to indomethacin.

History

First described by American ophthalmologist Richard K.Lansche in 1964 as ‘ophthalmodynia
periodica’. Further defined as “icepick-like pain” by Raskin and Schwartz in 1980.

Included as a separate entity in the classification of the International Headache Society (IHS) in 1988

• Severe, brief stabbing pain
• Often unilateral
• Typically in temporal or orbital distribution

Also referred to as:

• Ophthalmodynia periodica
• Jabs and jolts syndrome

Epidemiology

• Uncommon
• Affects both children and adults

Pathophysiology

• No identifiable structural abnormality
• Often coexists with migraine or cluster headache
• May represent spontaneous firing in sensitised individual nerve fibres

Clinical Features

Feature	Description
Nature	Sharp, electric, stabbing; mild to severe
Duration	Ultra-brief, lasting seconds
Pattern	Single stabs or volleys over 1–15 minutes; median episode duration ~2 weeks; recurrences up to 2 years
Distribution	Anywhere in the head; both trigeminal and extra-trigeminal; location may vary
Associated Features	Wincing common; no cranial autonomic symptoms (helps distinguish from TACs); often coexists with other primary headaches

Investigations

Recommended to exclude other causes when:

• Pain is strictly unilateral
• Pain is invariably localised

Imaging

• CT: Initial screening
• MRI: Preferred modality to exclude:
  • Structural lesions (e.g. malignancy)
  • Demyelinating disease

Management

No treatment required if attacks are infrequent and brief.

Persistent cases may benefit from:

Therapy	Notes
Indomethacin	75–150 mg daily – first-line
COX-2 NSAIDs	Alternative if GI side effects a concern
Melatonin	3–12 mg daily
Gabapentin	400 mg BD

Disposition

Refer to Neurologist for assessment and confirmation of diagnosis

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References

Publications

• Lansche RK. Ophtalmodynia periodica. Headache 1964; 4:247–9
• Raskin NH, Schwartz RK. Icepick-like pain. Neurology. 1980 Feb;30(2):203-5.
• Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Headache Classification Committee of the International Headache Society. Cephalalgia. 1988;8 Suppl 7:1-96.
• França MC Jr, Costa AL, Maciel JA Jr. Gabapentin-responsive idiopathic stabbing headache. Cephalalgia. 2004 Nov;24(11):993-6. 
• Brazis PW, Masdeu JC, Biller J. Localization in Clinical Neurology. 8e 2021
• Fuller G. Neurological Examination Made Easy. 6e 2019

FOAMed

• Coni R. Other primary headaches. LITFL
• Coni R. Headache classification. LITFL
• Coni R. Headache Essentials. LITFL