S4 E9: Ponytail, sex headaches and other primary headaches

A National Migraine Centre Heads Up Podcast transcript

Ponytail, sex headache and other primary headaches

Series 4, episode 9

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[00:00:00] Did you know, having brain freeze after eating ice cream is more common in people with migraine. The proper name is sphenopalatine ganglion neuralgia. Listen to this episode for more information on some unusual types of headaches. Welcome to the Heads Up podcast brought to you by the National Migraine Centre, the only UK charity treating migraine and headache.


Dr. Katy Munro [00:00:28] Hi and welcome to another episode of Heads Up podcast. And today we’re going to be talking about all sorts of primary headaches that can occur separately from migraine, which is our normal topic. And I am here today with Dr. Jessica Briscoe.


Dr. Jessica Briscoe [00:00:47] Hello. Nice to see you again, Katy.


Dr. Katy Munro [00:00:52] Still zooming, still far away, but hopefully we can crack on through this episode and then some day soon, we’ll be able to meet up in person.


Dr. Jessica Briscoe [00:01:03] So we thought we’d do this episode about some of the other types of headaches that we haven’t really mentioned. We may have mentioned in passing very briefly, but they don’t always get huge amounts of air time, because they are very, sort of- I think they’re quite significant whenever I’ve seen them in people, but they’re quite small in the headache diagnostic criteria. There are some ones that were asked for, I think, newspaper articles and magazine articles quite like them, don’t they, Katy?


Dr. Katy Munro [00:01:34] That’s kind of what nudged me to do it, because I did have a journalist ask me all about one of them. But yeah, and of course, because migraine is so common, people with migraine can also occasionally have one of these other primary headaches. So what’s the difference between primary headache and a secondary headache? What does that mean, Jess? Do you want to explain that?


Dr. Jessica Briscoe [00:01:55] Yeah. So primary headaches are everything that we think of as migraine, cluster headache, some of the other types of facial pain, and these other headaches, there where the headache disorders been caused- primarily that is the main cause of the headache. Secondary headache is where there is another biochemical or pathological process going on, where headache is more of a symptom rather than the primary diagnosis. So we think of things like infections. We think of things like- one thing that we all worry about, tumours and other sort of brain bleeds, stroke, trauma and after seizures sometimes you can get headaches and things like that. Those are all the ones that we worry about and everybody worries about if they’re important headaches, but they are much rarer actually.


Dr. Katy Munro [00:02:48] Yes. So one of the things that I was talking to the journalist about was about the difference between a primary and secondary headache, because she was asking about whether people with migraine were more likely to get ponytail headaches and was that a thing? And I was explaining to her that ponytail headache, or now as it’s called external traction headache, is actually a separate thing. So it’s not necessarily a sign that you’ve got migraine if when you put your hair up in a ponytail, it gives you a headache, and then when you shake it down, the headache goes away again. But I’m jumping ahead a bit. So the headache is a symptom, not a diagnosis. That’s the main thing, isn’t it? So we have a number of people who say, ‘Oh, I just get the normal headaches’. And I always say to them, ‘Well, why are you getting the headaches? Because you need to look behind the symptom and find out whether there is something causing the headache, because it’s not the diagnosis in itself’.


Dr. Jessica Briscoe [00:03:55] It’s one of my pet hates actually, when you see a referral letter, I know we don’t get them that much at the National Migraine Centre, or if you’re looking on one of the GP systems and you see ‘diagnosis: headache’. And you just think, ‘Oh, that’s not the diagnosis that’s the symptom’. It’s helpful to actually be able to know what’s causing the headache, what is the diagnosis, because it does make a difference in treatment. Because if you know- through research, they have found that some treatments are better for one type of headache than the other. I mean, we we talked about it with a tension-type headache versus migraine. Both incredibly common. But, you know, you do treat them very slightly differently even when you’ve had one of these attacks. So it’s important. We just call it all headache.


Dr. Katy Munro [00:04:42] It would be a bit like putting a diagnosis as, ‘diagnosis is rash’ or ‘the diagnosis is weakness’. And obviously that isn’t the diagnosis, that’s the symptom. And so, we find it easier as doctors to realise that those are symptoms and look harder for what the cause is. But I think sometimes people go, ‘Oh, you’ve got a headache, that’s it’. And, so it’s really sort of raising awareness about the fact that you need to search for more clues as to why the headache is happening. So these primary headaches are all outlined- all the ones we’re going to talk about, are outlined on the International Classification of Headache Disorders, version three, and I’m emphasising the version three because there are quite a number of changes to the way that we describe individual types of headache conditions and that was updated last in 2018. And I think it’s quite useful. I use it a lot now.


Dr. Jessica Briscoe [00:05:48] I use it a lot.


Dr. Katy Munro [00:05:48] So if you just go on to the Internet and type it in, it will be a very useful resource for anybody who wants to know how is this particular headache-type defined? And it clarifies some of the old fashioned names that have kind of gone out of use, doesn’t it?


Dr. Jessica Briscoe [00:06:08] I love the annotations bit at the bottom. There’s also, I mean, I have a special interest in the ICHD3. I do a lot of the social media, or some of the social media, as part of the team for the International Headache Society who actually are in charge of the International Classification of Headache Disorders, which is what ICHD stands for. And so I found that through- you find out all sorts of little nuggets when you have to do quite a lot of posts on them and there’s a little glossary at the end which tells you about all of the different symptoms that we talk about. And it’s actually quite nice as a non-specialist to be able to through that. But also, as you said, it tells  you all the old names for the headaches.


Dr. Katy Munro [00:06:49] What they used to be called.


Dr. Jessica Briscoe [00:06:50] Yeah. The thing that I really like to highlight about the ICHD3 criteria is that it is primarily a research tool. So it’s been developed so that people can research headache disorders properly. So sometimes, you know, it’s very specific. There are some things that I think most clinicians who work in practice would like to be added in as well. But actually from a research point of view, it’s not always possible. So that’s one thing I always like to point out.


Dr. Katy Munro [00:07:19] Yeah, it took me a little while to work out how to best use it. So what I’ve found is, if you go on to it, you see this kind of tree of subsets of titles of headache disorders, and if you click on the one you’re interested in, nothing pops up until you scroll scroll scroll down to the bottom of the page, and then you can see the ABCD – this is the criteria we use to make sure that that is the correct diagnosis. And then there’s some little comments there and often that gives a wealth of information, actually.


Dr. Jessica Briscoe [00:07:52] Yeah really useful.


Dr. Katy Munro [00:07:55] The other thing I wanted to flag up while we’re just, it just popped into my head then, the other useful thing for anybody who- for patients and for clinicians, is the newly updated BASH headache management system and we’ll put the links in the blurb because that’s got patient leaflets, but it’s also got a really good lot of information for doctors who are managing people with any kind of headache conditions.


Dr. Jessica Briscoe [00:08:20] Yeah, and I think that’s really- I was thinking about that too actually, great minds, Katy. Because actually someone brought it up in a talk that I went to by BASH (British Association for the Study of Headache) and it was one of the people who’d been on the NICE guidelines committee who admitted that actually, you know, looking back on it, sometimes it doesn’t make the management of which preventative to choose as clear or how to do it- how to actually increase the doses, which we’ve discussed a lot in our preventatives episode. And actually I think the BASH guidance is really, really clear on how exactly to give the medications and how to monitor them and things like that. So that’s a really useful tool.


Dr. Katy Munro [00:09:01] Very practical, useful information. Yeah. So talking about the primary headaches that we’re going to speak about, these rarer ones. They’re usually- you have to have had at least two episodes before you can say- so if you just had a one off episode of one of these conditions, then it wouldn’t necessarily be a diagnostic criteria for us saying, that’s what you’ve got. But usually when people come and present, it’s because they’ve had many more than two episodes, isn’t it?


Dr. Jessica Briscoe [00:09:36] Absolutely.


Dr. Katy Munro [00:09:36] They’re coded into about four different categories. And I’ll just quickly outline those. So one is associated with physical exertion. The next one is attributed to direct physical stimulation, and some are to do with pain over the scalp. And then there’s a, sort of, mixture of random other ones, and that includes things like Hypnic headache, which I think we mentioned in the sleep episode of the podcast, so if anybody’s interested in headaches that wake you up in the middle of the night, Hypnic headache, we went into quite a lot of detail in that episode.


Dr. Jessica Briscoe [00:10:18] So we’re going to look at nine specific ones.


Dr. Katy Munro [00:10:22] Yes.


Dr. Katy Munro [00:10:23] We’re not going to be here all night, though, Jess, are we?


Dr. Jessica Briscoe [00:10:27] No. Well, you and I could talk for England, so probably. Shall we start off with the primary cough headache which I was saying, I’ve seen a few of these recently. They’re like buses, you don’t see anyone with a certain type of headache for ages and then suddenly they all come. That’s the newer name for it and they used to be called- and sometimes you, like with all of them, you sometimes get other- the cough isn’t necessarily the precipitating symptom- the precipitating stimulus, but it used to be called the Valsalva headache. But this primary cough headache, it’s quite a rare condition. It counts as 1% or fewer of all headache patients in neurological clinic. And if you think about how many headache patients there are neurology clinics, that’s a very small proportion. There are a lot of headache in neurology. But it’s possible that they’re just not being seen in neurology clinic. I know it’s been reported that a fifth of patients with cough that are seen in chest medicine clinic, actually have a cough headache. So it’s possibly just not the symptom that’s bothering people so much.


Dr. Katy Munro [00:11:31] Yeah, it’s a sudden onset headache and it lasts anything from a few minutes up to a couple of hours. And I wonder whether, because of this pandemic, whether COVID and the coughing, you know, has made more people have this kind of cough headache, I think there’s a lot more complex reasons why people get headache when they’ve got COVID or when they’re recovering if they’ve got long COVID, which we know is a significant morbidity that kind of makes people feel ill for several months afterwards. But it’s an interesting one. I don’t know if anybody’s ever looked at whether primary cough headache is being diagnosed more frequently because more people have been coughing.


Dr. Jessica Briscoe [00:12:16] Yes, interesting possible future research area from us.


Dr. Katy Munro [00:12:19] Any researchers out there like to do that? So it’s usually on both sides of the head and at the back, and it’s usually in people who are older than 40. And there’s often a link between how frequently somebody is coughing and how bad the headache is, which kind of makes sense, doesn’t it, really?


Dr. Jessica Briscoe [00:12:40] Yeah, I think it’s one that tends to worry clinicians because we did talk about our red flags. And if someone- it’s more bending forward that you worry about, but coughing, any kind of Valsalva. So Valsalva, we have I think explained it before, but just again for awareness, it’s where you get an increase of pressure in the abdomen really so straining can do it, sneezing, coughing, going to the loo, things like that can all cause this increased pressure in the abdomen. And I think sometimes people can get a bit concerned about it. So if people are young I think they’re more likely to get sent for a scan. Or if they’re particularly old, so the different extremes. But, it may be one where people will have a scan, but we’re not expecting the brain scan to show anything abnormal?


Dr. Katy Munro [00:13:26] No, that’s true. So some people get dizziness or nausea or abnormal sleep with their primary cough headache. But of course, you know, that’s not definitive thing, because they get all of those things with migraine as well, don’t they? But if somebody is only having headaches that occur when they cough and they’re not having any other kind of headaches, then it is possible that they’ll get those other accompanying symptoms with it as well. Hopefully, those symptoms resolve quite quickly as well.


Dr. Jessica Briscoe [00:14:00] Yeah, traditionally, I find it quite a difficult one to treat because, you know, people come to the clinic, it’s quite a short-lived headache and, as I said, I think people tend to want to make sure it’s nothing more serious, but when it’s a short-lived headache like that you can’t necessarily treat each individual episode they might be getting one every so often. You give medication. But occasionally it’s just a case of sort of just reassuring and giving a diagnosis so people- that can be a treatment in itself. But there have been a few reports that indomethacin, which is a painkiller that we use sometimes for different types of headache, hemicrania continua and paroxysmal hemicrania we’ve talked about that for them, can be effective in treating it. But again, it’s not a very common headache, possibly people aren’t started on treatment. So I doubt- it doesn’t look like that there’s that much evidence behind it. But it is worth thinking about if people are getting troubled by it.


Dr. Katy Munro [00:14:55] Yeah, I guess if it’s coming very frequently and people are really, you know, needing to try and reduce the frequency, it’s worth a try with indomethacin. But that’s not a very easy medication to take either, is it? It has horrible side effects for some people.


Dr. Jessica Briscoe [00:15:10] I know. Real stomach issues with indomethacin, yeah.


Dr. Katy Munro [00:15:14] Yeah. So moving on. We’re going to talk about sex now, aren’t we? I think this is the first time we’ve done this on the podcast, isn’t it?


Dr. Jessica Briscoe [00:15:21] I know, we’ve managed to avoid it until now.


Dr. Katy Munro [00:15:22] So there’s one thing we have talked about and that’s- we’ve talked about the importance of seeking help if you had any of the red flags. I think that was in the ‘Do I need a scan?’ Episode right at the very beginning. And the people who are having a headache that comes on for the very first time when they’re having sexual activity, always need to go and get that checked out. I think that’s a real red flag. To make sure that it’s not caused by an underlying brain haemorrhage, like a subarachnoid or something like that. So if you’ve never had a headache when you’re having sex before and you suddenly get one, don’t ignore it and think, ‘Oh, well, I’ll see how I go over the next few days’. You do need to go and get that checked out. And that involves casualty or the emergency unit of your local hospital and talking to the doctors about whether you need a scan or more investigations. Would you agree?


Dr. Jessica Briscoe [00:16:25] Absolutely. I think this one, when when I was doing neurology when I was a lot younger, I did see a couple of these come through from A&E, actually, into clinics as well, just to sort of make sure that it was nothing more serious. They weren’t anything more serious, but it’s really important. We always agreed that it was an important thing to do.


Dr. Katy Munro [00:16:47] Yeah. I think it’s sometimes something that people hesitate to seek help about because they’re embarrassed. And also as clinicians, if somebody presents with a sudden onset, what we call like a thunderclap headache, we might not remember to ask, what were you doing at the time? Or we might ask it and the person might say, ‘Well, erm, oh, uh, I can’t remember…’ because they’re a bit embarrassed to say that it came on as they were having an orgasm or just before or sometimes just after. So it used to be called many different things, this one, didn’t it? Benign Sex Headache.


Dr. Jessica Briscoe [00:17:26] Coital cephalalgia. Coital headache.


Dr. Katy Munro [00:17:28] Intercourse headache.


Dr. Jessica Briscoe [00:17:30] Orgasmic cephalalgia. Sexual headache. Post sexual headache.


Dr. Katy Munro [00:17:35] Simple sexual headache. So they all basically- they used to be thought that there were two different types and people used to try and work out which type it was. One was called preorgasmic and the other was called orgasmic. But with the new classification that we were talking about earlier, the ICHD3, it’s now considered to be just one entity. So any headache associated with sexual activity is now regarded as the primary sexual headache.


Dr. Jessica Briscoe [00:18:03] Interestingly, this one is more common in males than females, bucking the trend of migraine. With men getting it sort of nearly twice as more frequently than females or- it is definitely more frequent in men than women. I think I’ve mainly seen it in men, I have seen it a few women.


Dr. Katy Munro [00:18:21] Yeah, I’ve seen it in men, now you’ve said that, yeah. I can’t think of any women although- yeah, it’s about, anything between 1.2 up to 3 men to 1 woman in terms of ratios, isn’t it? And it doesn’t seem to be affected by what type of sexual activity is happening and in most cases it’s on both sides of the head. But it can be on one side of the head in about a third of cases. So yeah, it usually starts like a kind of a dull ache on both sides and then as the sexual activity increases, it becomes more and more intense but it can come on quite suddenly at orgasm, can’t it?


Dr. Jessica Briscoe [00:19:13] It can really be like that thunderclap, some people talk about. That build up of intensity within seconds rather than anything longer than that.


Dr. Katy Munro [00:19:20] But different from migraine, it’s not normally associated with vomiting or any visual or sensory or motor symptoms, is it? Where migraine we often find people are saying, ‘Oh, I felt a bit sick or I’ve had the visual changes, blurred vision’ or whatever, and you don’t normally lose consciousness with it. It’s just a really painful headache.


Dr. Jessica Briscoe [00:19:41] So people tend to get symptoms afterwards? Do they get lingering headaches or anything like that in your experience?


Dr. Katy Munro [00:19:49] No, but they can get it back again. I have- I’m just thinking of the two men that I dealt with in the recent past and they did have headaches, kind of, going on for a day or two and then they went away again. And I think one then subsequently had it again. So, yeah. About 40% can run a bit of a chronic course, apparently, and last- be a bit of a nuisance for over a year. But they do tend to be, sort of, self-limiting I think.


Dr. Jessica Briscoe [00:20:26] You can actually give some things to help as well. So if people are getting them quite frequently. You can use the beta blockers like propranolol or atenolol as a preventative. Or you can try some medications prior to sexual activity as well. So the triptans, like we use in migraine and cluster headache conditions, can be used before sex or you can try indomethacin again an hour or so before sex, as long as there aren’t any reasons not to take it, you know, any gastric issues that would keep people from taking it.


Dr. Katy Munro [00:20:59] I think a lot of the time it’s about reassuring that there’s nothing more sinister going on. There’s no aneurism bleeding or anything like that. And once people know that it is a primary sexual headache then they can sometimes try alternative positions or try massaging the neck and shoulders or, you know, there are various other things people have tried, but I don’t think anybody has really studied that. There’s not much evidence for those.


Dr. Jessica Briscoe [00:21:27] I think it would probably be quite hard to recruit for those studies though, to be honest, it’s not going to be the easiest- I think that’s the nature of that type of headache can be really difficult to actually measure how well those different things work. Great. So next one is headache attributed to external application of a cold stimulus. So this is where you will get a headache following exposure of the head to really low temperatures- the environment temperatures. So thinking about some of the snowy weather that we sometimes get in winter or very very icy conditions.


Dr. Katy Munro [00:22:03] I get this sometimes, I recognise this one. So when you go out for a walk and you haven’t bought your woolly hat and the wind is really whistling around your head, that’s the sort of thing that you can then get really quite powerful headaches from it. The other time is if you dive into the sea.


Dr. Jessica Briscoe [00:22:22] Or cold water, I don’t do too much of that as we’ve discussed before. I’m guessing also if you- so sometimes we use freezing- liquid nitrogen- sometimes people can get them if you’re using quite a lot, probably for quite a large lesion.


Dr. Katy Munro [00:22:37] Yeah. So freezing skin lesions and things to try and treat warts or carcinomas or basal cell carcinomas or something like that I guess might be treated with cryotherapy. And it’s an intense, short lasting stabbing headache and it tends to be in the front- in the middle, at the front. It usually goes within about 30 minutes of the cold- so basically you need to warm up, get in out of the wind.


Dr. Jessica Briscoe [00:23:10] Where a hat!


Dr. Katy Munro [00:23:10] Where a hat, don’t forget your hat. And so, you know, if people are prone to getting this particular kind of headache, then yes, that is the most sensible thing because it’s a relatively short lived one. There’s not really any medication you need to take for that. It’s just a question of prevention.


Dr. Jessica Briscoe [00:23:28] Prevention.


Dr. Katy Munro [00:23:28] Remembering that if you get really cold you’re going to get a bad headache if you have primary- it’s very long this, isn’t it?


Dr. Jessica Briscoe [00:23:37] Headache attributed to external application of a cold stimulus.


Dr. Katy Munro [00:23:42] That’s it! So the next one is a bit more fun, in some ways.


Dr. Jessica Briscoe [00:23:45] And it’s actually related.


Dr. Katy Munro [00:23:47] Yeah. So it used to be called ice cream headache, but it’s now called headache attributed to ingestion or inhalation of a cold stimulus. So basically it’s brain freeze.


Dr. Jessica Briscoe [00:23:58] I always call it brain freeze headache.


Dr. Katy Munro [00:24:02] So this is an actual thing. It is recognised. And if you have ever taken a giant mouthful of ice cream and thought, ‘Ahhhh, my head is now exploding’, then you have had one of these types of primary headaches. It’s quite short lasting. It can be cold drinks as well. If you have one of those very iced slush puppy type things.


Dr. Jessica Briscoe [00:24:31] Yeah. I don’t know if they still exist but yeah, slush puppies, any kind of crushed ice drink. It says in the criteria that it’s brought on or occurring immediately after the cold stimlus of the palate and/or posterior pharyngeal wall. So ingestion of cold food, drink or inhalation of cold air, so I guess, actually again, if you’re outside, you breathe in and it’s quite icy and you’ve taken in quite a lot of cold air. I’ve had that before.


Dr. Katy Munro [00:25:02] Yes. That’s interesting. So people may have not got that so much when they’ve been wearing masks. I certainly felt wearing a mask in the colder weather was quite comforting. Didn’t get that sort of cold feeling in your face and head. This isn’t a serious headache. It isn’t anything to worry about. A lot of these primary headaches that we’re talking about today are nothing to worry about, as long as you’ve excluded the underlying cause, as we said for the previous one. And this one goes away quite quickly. I mean, how fast you eat your ice cream, apparently, doesn’t make any difference. Even if you eat your ice cream slowly, if you are a bit prone to this, you might get a brain freeze headache. But I don’t think that’s going to put most people off, is it?They’re going to eat their ice cream anyway.


Dr. Jessica Briscoe [00:25:49] I would. And then the next one is external compression headache. This one is a bit like when you’re wearing- I used to get it when I wore swimming caps, when I had to swim at school. When you wear something tight like a band, I don’t know why I’m using the video to show where it goes when this is audio.


Dr. Katy Munro [00:26:06] I can see what you mean.


Dr. Jessica Briscoe [00:26:09] So if you have a band across your head, usually across the forehead actually, it can be anything around the soft tissues of the head. A helmet, goggles during swimming or swimming caps, as I said.


Dr. Katy Munro [00:26:23] I think I recognise this one as well. I think with people who get migraine, and obviously both you and I do get migraine, I think you have got that extra sensitivity of the scalp as well. The scalp is often quite sensitive to touch or pressure. But this particular primary headache is talking about a headache that is specifically triggered by wearing a tight hat or goggles or whatever, and then goes away as soon as you take it off. So it’s a slightly different emphasis, but probably people who get migraine and more likely to get that.


Dr. Jessica Briscoe [00:26:59] Yeah, I think it’s due to sensitisation of those peripheral nerves and the nerves around the scalp that causes it. So that happens more in migraine but actually it’s the tightness- the tightening that compression can also cause that sensitisation which is what we suspect causes it. They say it should be brought on or occur within an hour of sustained compression, so wearing your hat for an hour. And then it’s resolved within an hour of removing that compression as well.


Dr. Katy Munro [00:27:26] Very specifically around that thing. And the same thing applies to the next one, which is called external traction headache. And this used to be called ponytail headache. And it was a journalist asking me about ponytail headaches that triggered me to think that we should do this episode because she was doing a piece on whether there was more ponytail headache because people in lockdown couldn’t get their haircut, and so their hair was longer and longer, and so more people were putting their hair up in a ponytail. So she specifically got ponytail headaches but didn’t have migraine. So if she put her hair up in a ponytail, she would get a headache coming on. And then if you took it down within an hour, the headache would go away.


Dr. Jessica Briscoe [00:28:17] It’s really interesting because I definitely see it. I mean, I definitely get it. As someone with very long hair, I get it when I have a migraine, but not necessarily without, so I think mine- so that thing within the migraine is actually that sensitivity of the scalp. So I think that’s probably more a migraine symptom than a ponytail headache. That’s that sensitivity of the nerves and that’s more of a symptom of my migraine rather than a headache in itself. I’m sure lots of people with migraine will be sitting there going, ‘Yeah, I know exactly what that one is like’.


Dr. Katy Munro [00:28:43] Definitely. I never put my hair up. I mean, partly because it’s quite short, but I can’t even where hairbands and things. It’s interesting that, really, I think what we’re describing highlights how the classification is very useful for research purposes. In daily life and in the people who come and talk to us in clinic there’s quite a bit of overlap of these symptoms, really.


Dr. Jessica Briscoe [00:29:09] Exactly. What if you got it at 61 minutes after you have put the hat on? Does that mean it’s not that? This is why you have to deal in real terms. It doesn’t always quite help the averages I think. Next one I’ve got- I quite like this one, well I don’t like the next one, I don’t like any of these headaches obviously.


Dr. Katy Munro [00:29:31] It’s interesting.


Dr. Jessica Briscoe [00:29:33] Yeah. And I think I’ve been more aware of it generally as the years have gone by, but primary stabbing headache. This is one that I always knew as icepick headache.


Dr. Katy Munro [00:29:42] Yeah.


Dr. Jessica Briscoe [00:29:43] There were lots of names, but the one that I think sounds horrible is needle in the eye syndrome. Though I certainly have had patients who’ve described that. And this is stabs of pain, usually quite well localised and transient, so they can happen every so often. So you can get short- they usually last quite a short period of time. And it feels like someone is stabbing you very directally. I’ve had people say, “It feels like someone is jabbing a needle through my eye, into the middle of my skull’. And it happens in the absence of organic disease or any problems with the nerves, so the absence of any kind of structural abnormalities. And there have actually been some studies on this one. It showed that 80% of the stabs last for 30 seconds or less, but people can have them lasting for longer, in between- it’s rarer- they can last between 10 and 120 seconds. They can be a bit more prolonged than that, you know, that jabbing sensation that you get.


Dr. Katy Munro [00:30:45] Quite a horrible feeling if you’re getting that sudden onset as if somebody is sticking a knitting needle or a skewer in your head, isn’t it? And it’s quite alarming to people even though it goes away. And you know, jabs and jolts was another name for it in the past. And we certainly hear this from people with migraines, as well, saying, ‘oh, well, I get my typical migraine features like this, but then sometimes I get this stabbing or jolting’ and I think again, there’s a bit of overlap. It’s more common to get it if you’ve got migraine and apparently the stabs tend to be more usually on the site where you normally get your migraine headache. So yeah, definitely a thing. And it’s not a particular cause for concern if you start to get primary stabbing headache, other than the fact that it’s not very nice.


Dr. Jessica Briscoe [00:31:39] Yeah. I was reading an intersting paper on this because I was talking to one of our colleagues about some of the more unusual- not unusual, but perceived unusual symptoms. And they’ve actually done a bit of research on the different- there are lots of different types of primary stabbing headache, which I just wasn’t aware of. So you can get them on both sides, you can get them on one side, they can be- you can get them occurring continuously for a period of time. You can get more of a chronic picks or you can get these more episodic picks where you get them every so often. And it can come with some of the symptoms that you get with migraine, that touch sensitivity, allodynia, that we talked about. That and a few other symptoms too. And they sort of postulated that that shows that there is something similar going on with the nerves, the peripheral and central nerves as with migraine. So sensitisation, increased sensitivity, yeah  simply it’s the nerves around the scalp or any area that the pain’s occuring. I wondered if that’s why we see it in people who get a high frequency- really high frequency, we see it quite a lot. They’re more likely to get these jabs of pain every so often and you wonder if that sort of process is what’s going on.


Dr. Katy Munro [00:32:52] The brain is on red alert all the time in people with more high frequency or chronic migraine, isn’t it, really? I mean, it’s ready to respond to every stimulus and go, ‘oh, that’s pain. that’s pain.’ So I guess that’s possibly why. It’s in children as well. Children can get this, too.


Dr. Jessica Briscoe [00:33:08] Yeah. Tehy’re always very good at describing and drawing this, I have to say.


Dr. Katy Munro [00:33:13] Yes. That’s a really useful thing to do with kids, isn’t it? Getting them to draw how they’re feeling or, you know, colour in something to show what they’re feeling is a useful thing.


Dr. Jessica Briscoe [00:33:25] Absolutely.


Dr. Katy Munro [00:33:26] So you don’t normally with this primary stabbing headache, you don’t normally get the autonomic symptoms, do you, that people sometimes get with migraine or cluster headache. So people with both of those conditions may get a red watery eye or a blocked nose. Sometimes they go pale on the, you know, a facial pallor, don’t they? But you don’t tend to get that with primary stabbing.


Dr. Jessica Briscoe [00:33:50] No, not usually. The next one is nummular headache. I always quite like the name of this one. It’s previously called coin-shaped headache. Nummular actually means coins-shaped.


Dr. Katy Munro [00:34:03] Yeah.


Dr. Jessica Briscoe [00:34:07] This is an interesting one. So as the name suggests, you get pain of different durations, I’ve seen it chronic, I’ve not seen it in an episodic way, of a coin- a well circumscribed area but usually coin-shaped circular area in the scalp of pain. People can draw it out, you ask people where it is and they will actually draw a circle on that part of the scalp where they’re getting it. And again, there’s no cause. There’s nothing under the scalp that’s causing it or any lesion or anything like that.


Dr. Katy Munro [00:34:45] Do they get more than one coin-shape on their head?


Dr. Jessica Briscoe [00:34:50] I haven’t seen more than one, but very rarely it has been reported that you can get two or more areas that are nummular, so that coin-shaped area on the scalp. But personally I haven’t seen it.


Dr. Katy Munro [00:35:07] No, I haven’t seen it. I think this one is quite a rare one but the size of the coin shape can be anything between one and six centimetres. That’s quite big.


Dr. Jessica Briscoe [00:35:20] I know.


Dr. Katy Munro [00:35:22] A big patch like that, that would be a hefty coin, wouldn’t it?


Dr. Jessica Briscoe [00:35:24] Bigger than any coin I know.


Dr. Katy Munro [00:35:26] Yeah but it can be big or small.


Dr. Jessica Briscoe [00:35:32] Again, I’ve seen it in migraine, probably for the same, again it’s probably that increased sensitivity of the nerves in that area again that causes it.


Dr. Katy Munro [00:35:42] And you were telling me that you sometimes have been treating that with local anaesthetic injections?


Dr. Jessica Briscoe [00:35:49] Yeah. A bit like a nerve block but because of where it is in the scalp, it’s quite a thin area, you wouldn’t really want to use steroids there. You’d do just local anaesthetic in the area and that seems to work quite well to numb it. And like with nerve blocks anywhere else, it would usually last between 6 and 12 weeks if it’s effective. But you don’t know if it’s going to be effective unless you try it, and actually it does show- in my experience, you should usually try it at least twice.


Dr. Katy Munro [00:36:18] At least twice with most nerve blocks, isn’t it, really? So the coin pain- the coin-shaped areas of pain tend to be on the side towards the back on the top of the head. It’s not kind of down near the neck or over the forehead usually, is it?


Dr. Jessica Briscoe [00:36:35] No, you’d probably think it was a different headache if it was in a different area.


Dr. Katy Munro [00:36:42] Yeah.


Dr. Jessica Briscoe [00:36:43] It doesn’t seem to sort of relate to any of those big nerve root areas.


Dr. Katy Munro [00:36:49] Yeah. So we’re coming on now to, we’ve nearly spoken about all of the ones on my list I think, Jess. The next one is the new daily persistent headache. And this used to be called chronic headache with acute onset. And I think this is a tricky one.


Dr. Jessica Briscoe [00:37:08] Yeah, I think it’s a really confusing name, new daily persistent headache, because the number of people who will say, ‘but it’s not new I’ve had this for years’, but it was new when it started, is the key. I think it’s quite- I do think it’s important to diagnose, to put a name to it. I think it is important. It’s something that I’ve often diagnosed by exclusion, I have to say, because I’ve often- it’s a bit of a confusing one. So we’ll go with the description first of all. So it is a persistent headache as it sounds like in the title. So it starts one day and then you just have it continuously, usually without any break. It doesn’t tend to have any characteristic features with it. It’s bothersome in the sense that you have pain. But unlike with migraines, you don’t tend to get light sensitivity, motion- you know, moving your head doesn’t make it worse. You’re not usually sick with it. You don’t get those cranioautonomic features. However, it can feel like a migraine or it can be that throbbing pain like with migraine. Unfortunately, you can get this with migraine. And I have seen it with people who’ve had migraine, but it’s a different headache. So people can sometimes say, ‘Well, yeah, I know I have got sensitivity to light and sounds and stuff’ because they have a migraine biology, which can be a bit confusing in that type of headache.


Dr. Katy Munro [00:38:40] One of the very significant things about new daily persistent headache sufferers is they remember the exact day that it started. They know when it started and they can tell you very clearly, ‘it was on the 25th of March and I’ve had it every day since then’. And so if they can’t do that and if they say, ‘well, I think it was around about March some time but I used to get headaches occasionally in the past when I was younger’, that’s not new daily persistent headache probably. So it is quite an unusual history because most patients are fairly vague about when their pain starts. The people with NDPH, I think, just remember it because it’s such a big change, they didn’t have a headache at all and then they had a headache all the time.


Dr. Jessica Briscoe [00:39:35] And according to diagnostic criteria, there are two types of this. There’s a self-limiting one that just resolves by itself without any need for any interventions from us. And then the one that we tend to see, the refractory one, the one where we will try different treatments. And again, we use the usual- we tend to go down the same route we would with migraine, trying to prevent it- and with tension-type headache it’s quite similar.


Dr. Katy Munro [00:39:57] Yeah.


Dr. Jessica Briscoe [00:39:58] And we usually try some of those. Sometimes we try nerve blocks, but they don’t always work. There’s not- there aren’t particular studies on what helps with this.


Dr. Katy Munro [00:40:09] I think it’s important to stress that you haven’t got new daily persistent headache if your headache started last Tuesday and it’s still there. You have to have had it for at least three months before we would think about calling it new daily persistent headache. It’s a long lasting condition. So some people will get a bad headache, they can tell you when it started because it wasn’t that long ago and it’s still there. But that doesn’t mean they’ve got this.


Dr. Jessica Briscoe [00:40:37] Absolutely. And it is also worth- if it’s on one side particularly, it’s always worth checking whether or not it’s hemicrania continua which we talked about in episodes before. Which is one of those indomethacin sensitive headaches, one-sided headache, what we call a side-locked headache and it will respond to indomethacin. If it’s- actually according to the diagnostic criteria, if it is side-locked and you think it’s new persistent daily headache but it responds to indomethacin you should call it hemicrania continua.


Dr. Katy Munro [00:41:11] Yeah and if clinicians are not sure they might sometimes say to a patient, ‘well, we’ll do an indomethacin test and let’s just try this over the course of the next four weeks’ and usually because hemicrania responds so beautifully to indomethacin, it melts the headache away and so it’s very useful to do that test. The problem I’ve found is that sometimes people can’t tolerate the indomethacin for long enough to know. The response can be very quick within a few days. But the idea is to try and stay on the indomethacin for four weeks to really get a complete resolution of the hemicrania.


Dr. Jessica Briscoe [00:41:52] And I was going to say, the key, also, is indomethacin is obviously a painkiller too. If it just dulls the headache away when you get to the top dose, it’s not indomethacin sensitive. I think that’s something that’s not always clear when we suggest to trial indomethacin. It should completely resolve to pass the indomethacin trial, as it were.


Dr. Katy Munro [00:42:16] Excellent. There are other primary headache disorders that we haven’t talked about. One of them is Hypnic Headache, which I mentioned earlier, which is in the sleep episode with our lovely guests who talk to us all about sleep and the way that migraine and cluster headache are affected by sleep. And there’s also the exercise one, and I think we covered that in our episode on Migraine and Exercise.


Dr. Jessica Briscoe [00:42:40] My favourite episode.


Dr. Katy Munro [00:42:43] So we’re just really thrilled that everybody is enjoying our podcast and has been giving us really lovely feedback. And just to say, we are still really desperate for financial support for both the National Migraine Centre and the podcast because the two go hand in hand basically. And the podcast has had to have rather a long pause since our last series because we’ve been inundated with people referring themselves for consultations. So if you would like to help us to keep going as an organisation and keep making the podcasts and offering appointments to people with any kind of headache, please follow the link on the blurb and give us a donation. No amount is too small and no amount is too big.


[00:43:35] You’ve been listening to the Heads Up podcast. If you want more information or have any comments, email us on info@NationalMigraineCentre.org.uk. Till next time.

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This transcript is based on a past episode of the Heads Up podcast and reflects information available at the time of broadcast – some facts may have changed or new treatments become available since.

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