Clinical pattern and response to treatment of primary stabbing headache: Retrospective case series study from a Portuguese tertiary hospital

Abstract

Objectives This retrospective case series study aimed to investigate the demographic and clinical patterns of primary stabbing headache (PSH). In addition, we tried to identify subgroups of treatment responses in a neurology outpatient consultation at a Portuguese tertiary hospital. Methods Clinical records were retrospectively reviewed and patients meeting the International Classification of Headache Disorders, 3rd edition, criteria for PSH were identified from January 2014 to December 2020. We collected data regarding demographic characteristics, clinical features of the headache, primary headache comorbidities, and information about treatment‐related do PSH. Results Of 1857 patients, 32 (1.7%; mean [SD] age of onset 56 [3.5] years) had the final diagnosis of PSH. Regarding headache characteristics, 20 patients (62.5%) reported episodes of stabbing in fixed locations and 12 (37.5%) in multiple areas; the duration of each attack was between ≤5 s (seven [21.9%]), 5–60 s (20 [62.5%]), and ≥60 s (five [15.6%]). In all, 18 patients (56.3%) had an episodic course (vs. six of 32 [18.8%] an acute course and eight of 32 [25%] a chronic course). In all, 17 patients started medical treatment (53.1%), with total or partial improvement in 10 (58.8%) of them. It was found that patients with pain in fixed locations had a better response to treatment when compared to patients with multiple locations, in a statistically significant way (eight of 11 vs. two of six, p = 0.023). Conclusion In our sample, the mean age of onset of PSH was >50 years and there was a wide range of PSH duration. The duration of each attack (>5 s), the pain in fixed locations, non‐daily episodes of the pain in each attack, and the intermittent course of headache were the most prevalent clinical features. Finally, patients with stabbing in localized areas had a better response to treatment.

Epicranial headache part 1: Primary stabbing headache

“…It is now accepted that PSH occurs in an extratrigeminal location in approximately 70–80% of PSH patients (5,16,17,20,21), in contrast to earlier studies where anterior locations such as the orbital, supraorbital, frontal, and temporal regions were common sites of pain in patients with PSH (1,2). A recent clinic-based study reported a lower prevalence of extratrigeminal stabs (53%) in 32 patients (22). Stabs can be multifocal and migrating from one area to another, which has been reported in 23–64% of patients with PSH (1,2,5,17,20,22).…”

“…A recent clinic-based study reported a lower prevalence of extratrigeminal stabs (53%) in 32 patients (22). Stabs can be multifocal and migrating from one area to another, which has been reported in 23–64% of patients with PSH (1,2,5,17,20,22). In patients with migraine, stabs tend to be localized to areas where migraine attacks frequently occur, and can sometimes occur during migraine attacks.…”

“…The location of stabs has been reported to be frontal, temporal, parietal, occipital, orbital, around the vertex, and even on the face (1,2,5,16,17,20–22). It is now accepted that PSH occurs in an extratrigeminal location in approximately 70–80% of PSH patients (5,16,17,20,21), in contrast to earlier studies where anterior locations such as the orbital, supraorbital, frontal, and temporal regions were common sites of pain in patients with PSH (1,2).…”

“…Such sporadic or a series of stabs can recur infrequently (e.g. once every few months or years) or as frequently as dozens or hundreds of attacks per day (5,17,22). Between stabs, patients are asymptomatic in typical cases.…”

“…From a long-term perspective, the clinical course of PSH can be monophasic, intermittent, or chronic daily (Figure 1) (2,17,22). In monophasic PSH, attacks are more frequently located in fixed areas with acute or subacute onset and daily occurrence, whereas chronic daily PSH has more migrating locations (17).…”