Primary stabbing headache is a rare disorder. Because it is rare, it is often misdiagnosed and not treated properly. This post was prompted by a patient with this condition I saw last week. She went undiagnosed for 45 years.
This 57-year-old woman has been having intermittent headaches since age 12. Her headaches would occur in bouts lasting anywhere from a few days to a couple of weeks. She’s had periods of up to a year without any headaches. Her latest period of daily headaches has been the longest – it has lasted almost 4 weeks and was still ongoing. Her headaches were left-sided and localized to the temple. The pain was very severe in intensity (9 on a 1 to 10 scale), sharp and stabbing in character. The pain lasted only a second but occurred 1-2 times an hour. She was having difficulty working as her work involved being in a videoconference all day long. She had no associated tearing, nasal congestion, nausea, or sensitivity to light or noise. She was taking 400 to 800 mg of ibuprofen with modest relief. During one of her previous bouts, she had tried gabapentin, 100 mg three times a day, which helped initially, but then became ineffective and she stopped it.
As is the case with all rare conditions, controlled treatment trials are very difficult to do. Anecdotally though, indomethacin, a strong anti-inflammatory drug, seems to be very effective. Gabapentin, which the patient tried in a small dose, has been also reported to help. I prescribed indomethacin as her first treatment.
If headaches persist or if indomethacin causes stomach upset or other side effects, I will start her on gabapentin, 300 mg three times a day. There are two other rare indomethacin-sensitive headache types – hemicrania continua and chronic paroxysmal hemicrania. A few reports suggested that an herbal supplement, Boswellia can be effective for patients who cannot tolerate indomethacin. After that, another reasonable option would be to try Botox injections. Botox has been reported to help hemicrania continua, chronic paroxysmal hemicrania, cluster, and other types of headaches. Because the area where she experiences pain is small and circumscribed, she will need a very small amount of Botox, making it relatively inexpensive.
