No, Those Stabbing Headaches Aren't Just A Migraine

It’s 1:05am. You’re deep in a peaceful sleep.

It’s 1:10am. You’re jolted out of that peaceful sleep by a blinding pain above one eye that nearly knocks you out of bed. Your eye fills with tears; that side of your face breaks out in a sweat. You can’t sit still. The pain is so bad that banging your head against the wall for a few minutes sounds like a reasonable option for relief.

This is a “cluster headache.” Most people are familiar with migraines—the most common severe headache, which affects 18% of women and 6% of men. And virtually everyone has had a classic stress or tension-type headache. But there are other, less common types of headache that can be even more debilitating, including cluster and ice pick headaches. Unfortunately, these headache disorders are often confused with migraines and can go misdiagnosed for years. But as a neurologist specializing in headaches, I want people to know that these are very different conditions and require their own treatment plan. Here’s what you need to know.

Cluster headaches affect about 1 in 1,000 people, and they are more common in men than in women. Like migraines, they are typically one-sided and involve severe pain, but that’s where the similarities end.

Cluster headaches tend to occur for shorter periods than migraines, about half an hour to two hours, and “cluster” in time—hence the name. People go through cycles of having them every day, or multiple times a day, and then periods of not having them at all. People with cluster headaches also experience autonomic symptoms—redness and/or drooping of the eye, nasal drainage, tearing, and sweating on the affected side—which occur when the autonomic nervous system is damaged. There is also a sense of agitation. Where the migraine sufferer wants to lie down in a dark, quiet room, the patient with cluster headaches can’t sit still and tends to pace and rock, or even hit their head against the wall. Cluster attacks commonly occur overnight, waking people from their sleep.

Ice pick headaches also involve severe, stabbing pain, but episodes are much shorter. Each “jab” of an ice pick headache can last less than a second, or for several minutes. The pain can occur only once, or as a series of stabs. The pain is usually localized in the eye or temple. While ice pick headaches are extremely intense, their brief duration usually means they are less painful than cluster headaches.

There’s still a lot we don’t know about why people get cluster headaches, or what sets off a cluster cycle. What we do know, however, is that it involves the dilation of blood vessels in the trigeminovascular system, part of which controls sensation in the face, as well as the brain structures that regulate your sleep, pain generation, and the autonomic nervous system. But why this happens remains unclear.

Some of the external triggers that set off migraines, like changes in the weather or particular types of food, do not appear to play a part in cluster headaches. Alcohol consumption and smoking, however, do appear to be cluster triggers. Research also suggests that in about 10% of cases of cluster headaches, some genetic factors are involved.

Another factor that may set off cluster headaches is changes in the cycles of light and dark, because these shifts can affect your circadian rhythms—the natural internal clock that regulates sleep-wake cycles. A number of studies suggest that there is a relationship between circadian rhythms and cluster headaches. So, for example, flying between different time zones can be a trigger. For one of my patients, traveling from the United States to Europe for business always sets off a round of cluster headaches.

About 2% of the population experiences ice pick headaches, and it’s more common among people who also have migraines or cluster headaches. These headaches are part of a group of disorders called idiopathic stabbing headaches—“idiopathic” meaning the cause is unknown. Usually, ice pick headaches do not have any serious underlying cause, but any new onset of stabbing headaches should be checked out with your doctor.

Treating cluster headaches can be challenging, because the pain becomes very severe very quickly. We take two approaches to treating them: preventing the attacks in the first place, and relieving the pain when the attacks occur.

To prevent a new round of cluster headaches, pain management specialists have usually prescribed either verapamil, a medication commonly used to treat high blood pressure; topiramate, an anti-seizure medication; or prednisone, a steroid. All three of these drugs have been found to be effective in reducing the frequency, intensity, and duration of cluster attacks.

Within the last year, the first medication was approved specifically for the prevention of episodic cluster headaches—Emgality. Patients receiving once-monthly injections of Emgality experienced an average of 8.7 fewer weekly cluster headache attacks, compared to 5.2 fewer attacks for patients given placebo.

But when a cluster headache hits, you need relief urgently. Fortunately, we know that acute cluster headaches respond very well to oxygen. And while it might not be a convenient solution for all sufferers, one study showed nearly 8 in 10 patients using inhaled high-flow oxygen were able to abort about 80% of cluster attacks. The migraine drug Imitrex, given either as an injection or nasal spray, has also been proven effective at relieving the acute agony of cluster headaches.

Another new option is gammaCore, a hand-held device that delivers noninvasive stimulation to the vagus nerve in the neck. It was just approved by the FDA for cluster headache treatment in the last year, and studies have found that it reduces the frequency of cluster attacks. It has minimal side effects and can be used in combination with other treatments.

Managing ice pick headaches is more challenging, because the pain is over before any treatment can take effect. If you’re getting them often enough, however, the prescription nonsteroidal anti-inflammatory drug (NSAID) indomethacin blocks inflammation and reduces pain. It’s often used to treat headaches, including ice pick headaches and migraines.

For all forms of headache, I advise my patients to stay well hydrated and reduce alcohol use.

If you struggle with cluster or ice pick headaches, help is available. A neurologist who specializes in headache disorders can help you get the proper diagnosis and the right kind of treatment. You can also find support and advice at ClusterBusters.org, a nonprofit research and educational organization dedicated to cluster and related headaches. The approvals of Emgality and gammaCore just within the past year clearly demonstrate that these conditions are receiving more attention than ever, and that research is paying off with effective therapies. Don’t lose hope!

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