A 23-year-old woman consulted with the complaint of short-lasting, severe stabbing headaches and mild-to- moderate degree near-daily migrainous headaches.
Brief Communication Extracephalic Stabbing Pain Temporally Related to Cephalic Ones Macit Hamit Selekler, MD; Sezer Sener Komsuoglu, MD
A 23-year-old woman consulted with the complaint of short-lasting, severe stabbing headaches and mild-tomoderate degree near-daily migrainous headaches. Further questioning revealed that she also had stabbing pain on both ipsilateral hand and calf. Stabs on the hand were time-locked to cephalic ones and stabs in the calf were alternating with the ones in the hand. Dizziness and scotomas were accompanying symptoms to cephalic ones and paresthesia was the accompanying symptom in the hand. Patient’s cephalic and extracephalic stabbing pains responded to indomethacine and daily headaches responded to prophylactic sodium valproate therapy. The stabs were felt in the head; hand and calf are considered as the parts of a whole. Along with its accompanying symptoms, stabbing pain may be the result of complex interactions in central nervous system. Key words: stabbing, pain, headache, extracephalic Abbreviations: ISH idiopathic stabbing headache; ESBA extracranial stabbing and burning pain associated with allodynia (Headache 2004;44:719-721)
We reported a 23-year-old woman, who suffers from both migraine and stabbing pain, which occur in extracephalic localizations as well, such as ipsilateral hand and calf, temporally following a stabbing pain in the head.
Idiopathic stabbing headache (ISH) has been described by the International Headache Society (IHS) as “transient stabs of pain in the head that occur spontaneously in the absence of organic disease underlying structures of the cranial nerves.” Pain is confined to the head and predominantly felt in the distribution of the first division of the trigeminal nerve.1 Quality of ISH could be like stabbing of ice-pick, needle, nail, or pinprick.2 The ISH response to indomethacine treatment could be well, partial, or lacking.3 Although pain predominantly or exclusively occurs in the orbita, temple, or parietal areas; retroauricular, occipital,4 and cervical area have also been reported.5 Sjaastad et al6 have recently reported 17 cases with stabbing pains in unusual localizations such as facial and nuchal areas and throughout the body.
CASE REPORT A 23-year-old woman consulted with the complaint of short-lasting, severe stabbing headaches and mild-to-moderate near-daily headaches. Single stabbing occurred with the duration of a fraction of a second, in only one area over the head. The most frequently involved area was the temple and was followed by parietal area. She described the pain like stabbing of a knife, followed by a feeling as if there was “a red hot cinder” in the same area with the duration of 5 to 10 seconds and then all she felt was a paresthesia. With the feeling of a stabbing knife, she felt herself about to fall and had dizziness for approximately 10 minutes. As soon as stabbing occurred, she saw a flash like light and then her vision dimmed. Following that, she described “shining stars” on a black background.
From the Department of Neurology, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey. Address all correspondence to Dr. H. Macit Selekler, Department of Neurology, Kocaeli Medical Faculty, Derince 41900, Turkey. Accepted for publication February 17, 2004.
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720 Further questioning disclosed that during the period of dizziness she felt paresthesia on the first and second digits of her hand and pin-prick sensation on dorsum of her hand, which is ipsilateral to the stabbing. Stabs like pin-prick on the hand occurred periodically twice in a second, and lasted approximately 1 minute. As she was expecting another pin-prick on her hand, pin-prick skipped the hand and occurred in her ipsilateral leg’s calf; which was about once every 20 pin-pricks on the hand. With cessation of the pinprick sensations, paresthesia on the hand also disappeared but paresthesia on the head remained about for 10 minutes. In her headache history, there were stabbing headaches and episodic migraine headaches for 8 years. Episodic migraine attacks got more frequent and became near-daily for 2 to 3 months. These mildto-moderate headaches gained or lost migrainous features according to the severity of headache. While stabbing headache occurred 1 to 2 times a month previously, stabs began to occur more frequently (4 to 5 times a day) and more severe for 2 months while usual stabbing localizations remained the same. Her past medical history was unremarkable except for nervous tension. Neurological and physical examinations did not suggest any of the disorders in groups 5 to 11 listed by IHS. Neither sensory abnormality nor trigger point was determined with the palpation of the scalp. Her cranial MRI scan, EEG, and routine blood tests were completely normal. She was prescribed 50 mg indomethacine three times a day. With the initiation of the therapy, stabbing pain occurred only once without the accompanying symptoms during 1-week period, however, a mild degree of migrainous headache continued. Indomethacine was stopped because of gastric upset and sodium valproate was commenced and gradually increased to 500 mg per day in 2 weeks. At the end of the 3 months of follow-up period, she was headache-free and stabbing pains were very rare, ie, once a month, and mild, just as a pin-prick sensation without any accompanying symptoms, and only confined to the head.
COMMENTS In the Vaga study6 of headache epidemiology, 1779 subjects were asked about short-lasting paroxysms and
July/August 2004 some subjects reported several variants in respect to localization. Such variants were facial (n = 3), nuchal (n = 12), and throughout the body (n = 4). In one case, facial jabs appeared both before migraine attacks and without any temporal relation to such attacks. When antedating a migraine attack, there could be volleys of jabs on the migraine side, which seemed to shift. Sjaastad et al6 commented that as facial jabs have the same qualities as cephalic jabs, only with another localization; face seems to be a rare localization for jabs. Jabs occurring throughout the body were only solitary and there were no volleys. The interval between paroxysms was usually long. Jabs occurred in one area, once or repetitively at one time, and then occurred in an entirely different area the next time.6 According to Sjaastad et al,6 it is more likely that there is a fundamental difference between jabs that are and that are not stereotyped as regards to localization. Short-lasting, apparently rather homogenous paroxysms have the same background and same pathogenesis, that is, they might have a localized, underlying dysfunction, irrespective of whether there is an anterior or posterior cephalic localization of the jabs; and those with a steady shift of location could originate in the periphery (nerve irritation?).6 In our patient, stabbing-of-a-knife sensation on the head, followed by pin-prick sensation on the ipsilateral hand and on the calf were considered as a cascade of events. Therefore, we thought that all stabs occurring in different localizations were parts of a whole, although nature of the stabbing on the head and on the extremities was different. Recently, Piovesan et al7 have reported a patient with history of migraine, who developed cranial and extracranial (limbs and abdomen) stabbing and burning pain (ESBA) associated with allodynia, which was independent of migraine attacks; however, both migraine attacks and ESBA resolved with β-blocker therapy. They suggested that ESBA should be included in the category of migraine-related or migraine-like disorders. There may also be a relationship between migraine transformation and increasing frequency, severity, and extended distributions of stabs in this patient. Maybe, we could derive the same speculation as Piovesan et al,7 susceptibility to sensitization is present
Headache in both disorders. Positive response to both frequency of migraine attacks and stabs with propranolol therapy in Piovesan et al’s case and response to sodiumvalproate therapy in our case seem to be supporting this view. Accompanying symptoms such as visual ones, dizziness, and paresthesia on the hand seem to be the other parts of the whole although it is difficult to explain their relationship to stabs. So far, various interesting relationships between ISH and primary headaches have been reported; ie, migraine (stabs heralded the onset of a migrainous episode or succeeded the attack)2 and cluster headache (stabs becoming more frequent as the attack abated).8 A number of remarkable accompanying symptoms to ISH such as scintillating scotomas,2 dizziness, nausea,9 paresthesia of hands or face,2 even syncope,2 and transient monoocular visual loss10 have also been reported. What we can obtain from the available data today is the hints of possibility of complex interactions in the central nervous system during the occurrence of stabbing pains.
REFERENCES 1. Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia. 1988;8(suppl 7):1-96.
721 2. Raskin NH, Schwartz RK. Ice pick-like pain. Neurology. 1980;30:203-205. 3. Lance JW, Goadsby PJ. Miscellaneous headaches unassociated with a structural lesion. In: Olesen J, Tfelt-Hansen P, Welch KMA, eds. The Headaches. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2000:751-762. 4. Martins IP, Parreria E, Costa I. Extratrigeminal icepick status. Headache. 1995;35:107-110. 5. Piovesan EJ, Kowacs PA, Lange MC, Pacheco C, Piovesan LR, Werneck LC. Prevalence and semiologic aspects of the idiopathic stabbing headache in migraine population [abstract]. Arq Neuropsiquiatr. 2001;59:201-205. 6. Sjaastad O, Pettersen H, Bakketeig LS. Extracephalic jabs/idiopathic stabs. Vaga study of headache epidemiology. Cephalalgia. 2003;23:5054. 7. Piovesan EJ, Young BW, Werneck LC, Kowacs PA, Oshinsky ML, Siberstein SD. Recurrent extratrigeminal stabbing pain and burning sensation with allodynia in a migraine patient. Cephalalgia. 2003;23:231234. 8. Ekbom K. Some observations on pain in cluster headache. Headache. 1975;14:219-225. 9. Soriani S, Battistella PA, Arnaldi C, et al. Juvenile idiopathic stabbing headache. Headache. 1996;36:565567. 10. Ammache Z, Graber M, Davis P. Idiopathic stabbing headache associated with monocular visual loss. Arch Neurol. 2000;57:745-746.
