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Primary stabbing headache: the need for a definition for children and adolescents

Primary headache disorders are common in children and adolescents, with migraine and tension-type headache being the most commonly reported in the literature. However, not much is written on uncommon, but equally important, headache disorders such as primary stabbing headache (PSH). PSH is an ill-defined and poorly understood headache disorder characterized by a very brief (<3s), sudden, and severe pain affecting any part of the head. It is described as a stab, a jolt, or ‘icepick’ pain. The episodes may happen as single or repeated stabs many times in succession. Unlike headaches of trigeminal autonomic cephalalgias, there are no associated autonomic changes on the face, eyes, or head. The diagnosis of PSH is made in most patients on the basis of the clinical presentation and on fulfilling the criteria of the International Classification of Headache Disorders, third edition (ICHD-3). Neuroimaging may be necessary if the headache is atypical, side-locked (always affecting the same side), or there is no recovery between episodes. The prevalence of PSH in children is not known, but it is considered rare as only a relatively small number of patients are seen at specialist and tertiary headache clinics. Thus, the rare occurrence of PSH in children makes the study by Ahmed et al. timely and useful. The authors report on 42 children with a potential diagnosis of PSH and demonstrate the difficulties in assessment of clinical features and duration of attacks in particular: seven children reported attacks lasting less than 3 seconds, eight had attacks of more than 3 seconds and less than 2 minutes, and 27 patients had attacks lasting between 2 and 10 minutes. Until there are specific diagnostic tests for PSH, and indeed all other types of headache, clinical criteria will continue to be needed. The current ICHD-3 criteria for PSH have evolved over the past 30 years and will continue to evolve as evidence becomes available. In the first edition of the ICHD (1988), stabs were described as exclusively or predominantly felt over the distribution of the first division of the trigeminal nerve and lasting for a fraction of a second. In the second edition (2004), the stabs were described to last for up to a few seconds. In ICHD-3 beta (2013) and ICHD-3 (2018), the stabs were described as head pain without a specific location on the head and in some cases stabs may last for up to 120 seconds, with the location outside the trigeminal region in over 70% of cases. Also, a category of probable PSH was introduced in the ICHD-3 beta and ICHD-3 which there is no requirement for a definite duration of the stabs if other conditions are fulfilled. Specific criteria for the diagnosis of PSH in children are lacking and studies on larger numbers of children and adolescents with PSH will help in making the diagnosis clearer. Management of children with PSH depends on the frequency of attacks and their impact on the child’s quality of life and education. Making the correct diagnosis helps the child and the family understand and deal with the condition. Medical treatment may be necessary in some patients who experience a high number of stabs per day that interfere with school attendance and family and social life. Indomethacin in a dose of 25mg three times a day, with omeprazole to protect from gastric side effects, can be very successful in reducing and stopping attacks. Once remission is induced and maintained for 6 to 8 weeks, the medications can be stopped. Moving forward, studies on the long-term follow-up of children with PSH are needed to establish the natural course of the disease.