Primary stabbing headache has been known for several decades. However, the pathophysiology of this disease is not still understood. It is clinically characterized by single episodes or short-lasting series of stabbing pain recurring from once to many times per day in an irregular pattern. The diagnosis is clinical and any other possible cause should be excluded. The therapeutic approach indicates Indomethacin as the first choice of treatment, although case reports describe a therapeutic response to Melatonin, Celecoxib, Nidedipine, Paracetamol and Gabapentin. We describe the case of 5 patients with diagnosis of primary stabbing headache without comorbidity of anxiety or depression that shows a partial response to Indomethacin, but do respond to Benzodiazepines. There is little on the use of Benzodiazepines in primary headaches. They are used in patients with chronic migraine when there is a comorbidity of anxiety and depression. The unexpected efficacy of these molecules in our patients is encouraging and represents a hint to think about using these molecules in other types of primary headaches.
Primary stabbing headache (PSH) was first described in 1964 by Lasche as “ophthalmodynia periodica” [
The head pain is characterized by episodes of single or series of stabbing pain that last few seconds and occur from one to many times per day without a regular temporal pattern. The episodes involve the trigeminal or more frequently the extratrigeminal region. Moreover, the pain may shift from an area to another, in either the same or the opposite hemicranium. In addition, the pain has a fixed location in only one third of the patients in general [
Indomethacin represents the principal option for treating PSH despite therapeutic failure in up to 35% of the cases. Recent reports showed that Cyclooxygenase-2 (COX-2) inhibitors, Gabapentin, Nifedipine, Melatonin and Paracetamol may also be effective [
We describe the case of 5 patients suffering of PSH following the criteria of the ICHDIII beta that respond only partially to Indomethacin but do respond to Benzodiazepines.
In the following, we present the symptoms and treatment of five patients who suffered of PSH.
The first patient was a 47-year-old woman assessed in 2012. The patient had been suffering from stabbing right temporal headache that appeared several times a day since 2 months. The neurological examination consisting in assessing the higher nervous functions, cranial nerves, motor ans sensory system and reflexes, was normal. A brain MRI and Angio MR were entirely normal. A five days treatment with Indomethacin 50 mg bid reduced partially the pain. She was therefore treated with bromazepam from 0.5 to 3 mg tid. The headache resolved after a few days of therapy and did not recur even after the discontinuation of the therapy 4 months after.
The second patient was a woman aged 58 assessed in 2013. She presented since 20 days a series of stabbing headache bouts of which each lasted no more than a few seconds. Each of the bouts had an overall duration of at most 1 minute. The episodes had an average frequency of 3 - 4 times per day without associated symptoms. The patient did not suffer from any other type of primary headache. Neurological examination and brain MRI and Angio MR were entirely normal. A thermography was performed to study the autonomic nervous system involvement, resulting in no sympathetic activation in both the first and the second trigeminal branch. The patient was administered Indomethacin 50 mg twice per day for a duration of 5 days and had a partial improvement. Thereafter, Bromazepam was prescribed. The dosage of this medication was increased slowly from 0.5 mg to 3 mg three times per day. The symptom recovery occurred within a few days.
The third patient was a 54-year-old man assessed in 2013 for periorbital stabbing pain recurring 3 to 5 times per day over the prior 18 months without autonomic associated symptoms. A brain neuroimaging performed prior to the examination showed no abnormalities. The neurological examination performed during the medical visit was normal. A treatment with Indomethacin 50 mg bid for 5 days was introduced with no result. The patient was therefore administered Bromazepam slowly increased up to 3 mg tid with an almost complete resolution of the stabbing pain after few days. A month after the therapy was discontinued with worsening of the stabbing pain. Thus, the Benzodiazepine was reintroduced with benefit for 6 months. After two years the patient has sporadic episodes of short lasting stabbing pain. He is still on Bromazepam at the lower dosage of 1.5 mg tid.
Patient 1 | Patient 2 | Patient 3 | Patient 4 | Patient 5 | |
---|---|---|---|---|---|
Age | 47 | 58 | 54 | 58 | 33 |
Gender | Female | Female | Male | Male | Male |
Onset | 2 Months | 3 Weeks | 18 Months | 12 Months | A Month |
Number of crisis/day | 6 - 7 | 10 | 3 - 5 | 100 | 50 |
Frequency | Daily | Daily | Daily | Daily | Daily |
Response to indomethacin | Partial* | Partial* | None | Partial* | Partial* |
Associated headache | None | None | None | None | Migraine |
HAM-D | 4 | 5 | 3 | 4 | 4 |
Therapy | Bromazepam | Bromazepam | Bromazepam | Bromazepam | Alprazolam |
*Partial: reduction of the frequency and or intensity of stabs less than 50%; HAM-D: Hamilton Depression Rating Scale.
The fourth patient was a man aged 58 and examined in 2014 for daily occurrences of highly recurrent right parieto-temporal headache without associated neuro-vegetative symptoms. The episodes have been occurring since a year. The neurological examination as well as the brain MRI and MRA were normal. The symptoms slightly reduce after a five days treatment with Indomethacin 50 mg bid. Therefore Bromazepam 3 mg tid was initiated with progressive and complete resolution after a month. Bromazepam was reduced to 2 mg tid because of drowsiness, which disappeared with the tapering of the medication.
The fifth patient was a 33-year-old male with no clinical history except for sporadic attacks of migraine. He was examined 10 months ago for a right temporal stabbing headache with a severe short lasting pain occurring several hours per day since a month. Neurological examination and a neuroimaging scan were normal. Therapy with Indomethacin 50 mg bid for five days reduced only partially the symptoms. A second treatment with Alprazolam 0.50 mg tid was introduced. The treatment led to a complete resolution of the headache after only few days. The patient is asymptomatic after the discontinuation of the treatment.
All our patients had a normal score at the Hamilton Depression Rating Scale.
All the drugs used by patients were prescribed by physicians and bought in a pharmacy choose by the patient.
PSH is one of the Indomethacin responsive headaches, which represent the first line treatment for this pathology [
In the patients who do not tolerate indomethacin or are not relieved by the medication, the management of PSH become a challenge. However other drugs that may be helpful in the treatment of PSH has been pointed out by other observations.
Melatonin on the strength of its possible pain-relieving properties, was administered to three patients with PSH to assess its effectiveness, in a study by Rozen [
A therapeutic approach with Celecoxib, a COX-2 specific inhibitor, was described by Piovesan et al. [
Gabapentin (400 mg bid) was described by Franca et al. [
Slowrelease Nifedipine (90 mg/day) was effective in a case report described by Jacome [
In a pediatric population, Fusco et al. [
All our patients underwent a first therapy with Indomethacin 50 mg twice per day for 5 days with partial or no benefit. A Benzodiazepine treatment was subsequently introduced.
After only few days of treatment (3 to 10), they all had the complete recovery from their symptoms without collateral effects except a case of drowsiness that disappeared with lowering of the dosage of the molecule.
We chose to use a second line therapy with Benzodiazepine because of the gabaergic moduling of pain threshold of these molecules.
A reduction in the GABAA -mediated endogenous inhibitory control within the central nervous system leads to exaggerated pain and hyperalgesia [
There is not much in the literature on the treatment of PSH. The papers are all case reports which describe a therapeutic response to Indomethacin, Melatonin, COX-2 inhibitors, Nifedipine and Gabapentin. None of these therapies has been evaluated in controlled trials.
There is also little on the use of Benzodiazepines in primary headaches. They are commonly used with excellent results in patients with chronic migraine when there is a comorbidity of anxiety and depression. The mechanism for this improvement remains unclear. It may be due to the activity on anxiety and depression, or to the Gabaergic moduling of pain threshold of these molecules as explained before. This is the reason why we choose to use Benzodiazepines in a pathology that is scarcely affected by psychiatric conditions, and we select patients without anxiety or depression comorbidity, as shown by the normal score at the HAM-D.
Ours is a case report with few patients but the unexpected degree of efficacy of Benzodiazepines shown by our result is encouraging and represents a hint to think about using these molecules in other types of primary headaches.
A larger patients cohort is necessary to confirm our results.
Gaelle K. Ngonga,Daniela Carli,Paola Zavarise,Stefano Vollaro,Giorgio Dalla Volta, (2016) New Therapeutic Approach to Primary Stabbing Headache. Open Access Library Journal,03,1-4. doi: 10.4236/oalib.1102529