Neuropharmacology & Neurotherapeutics
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Primary stabbing headache …
- Updated 04.15.2025
- Released 09.02.1994
- Expires For CME 04.15.2028
Primary stabbing headache
Introduction
Overview
Primary stabbing headache presents as abrupt, ultrashort-lasting (< 3 seconds), focal or multifocal stabbing pain in the head that may occur sporadically or in clusters. According to The International Classification of Headache Disorders, 3rd edition, sharp stabbing pain is no longer restricted to the first division of the trigeminal nerve. Patients, especially children, reported stab durations longer than a few seconds, which may indicate that the ICHD-3 criteria must be adjusted. Indomethacin is the primary therapeutic option for this type of headache; however, melatonin has been shown to be effective in some cases. Primary stabbing headache can occur in isolation, but it is frequently comorbid with other primary headache disorders, such as migraines. The differential diagnosis should include secondary etiologies of stabbing headaches.
Key points
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• Primary stabbing headache is typically a benign self-limited primary headache disorder that consists of sharp stabbing head pain. | |
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• Age, gender, and whether the headache is comorbid with migraine influence the frequency of primary stabbing headache. | |
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• Imaging is a reasonable option to exclude secondary causes. | |
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• Indomethacin is the first-line treatment for primary stabbing headache. | |
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• Other therapeutic options include melatonin, gabapentin, and celecoxib. |
Historical note and terminology
Primary stabbing headache was first described in 1964, at which time it was termed "ophthalmodynia periodica" (18). Since then, brief, sharp, jabbing pains that occur either as single episodes or in repeated flurries have been designated by various terms including: "icepick-like pains," "sharp short-lived head pains," "needle-in-the-eye syndrome," and "jabs and jolts syndrome" (32; 38; 21; 41; 25). The International Classification of Headache Disorders, 3rd edition, uses the term "primary stabbing headache," classified under item 4—Other primary headaches.
Clinical manifestations
Presentation and course
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• Most patients with primary stabbing headache experience brief attacks (< 3 seconds). | |
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• Patients with primary stabbing headache do not have accompanying autonomic symptoms. | |
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• The presentation of primary stabbing headache in children and adolescents varies widely and sometimes includes a family history. | |
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• Patients, especially children, reported stab durations of longer than a few seconds, which may indicate that the ICHD-3 criteria should be adjusted. |
Primary stabbing headache is characterized by brief, sharp, and severe jabbing pain in the head that occurs either as a single episode or as a brief repeated volley. The International Classification of Headache Disorders (ICHD) has formulated criteria for this diagnosis (Table 1) under the term 4.7 “primary stabbing headache” (12). The pain resembles a stab from an icepick, nail, or needle, and it typically lasts from a fraction of a second to 1 to 2 seconds. Primary stabbing headache may have the shortest duration of all known headaches. The frequency of attacks varies significantly, ranging from one attack annually to 50 attacks per day. The pain was originally believed to be isolated from the distribution of the trigeminal nerve; however, studies have shown that 53% to 80% of patients with primary stabbing headache experienced stabs throughout the extratrigeminal location (17), and the diagnostic criteria of ICHD-3 have removed this location requirement for diagnosis. Icepick-like pain is more common in women and has been reported children (01).
Table 1. ICHD-3 Diagnostic Criteria for Primary Stabbing Headache
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(A) Head pain occurring spontaneously as a single stab or a series of stabs and fulfilling criteria B and C |
Most stabs last 3 seconds or less and rarely last for 10 to 120 seconds (08). These pains are typically unilateral but may be bilateral. They occur primarily around the parietal region (44.4%), followed by the frontal (21.5%) and occipital regions (13.9%) (26). The attacks also typically recur in the same area. If they occur in patients with other types of headaches, they are characteristically located on the same side and frequently at the same site as customary headaches.
The attack frequency is generally low, with only one or a few attacks daily. Significant variability exists in the temporal patterns of attacks. Most patients experience only a single jab, although some may experience volleys in the jab. Attacks can occur up to 50 times daily.
Notably, 38% to 74% of patients experience jolts, which are sudden movements that occur along with stabs (08; 15). Vocalization has also been reported in 18% of patients (08). Clinical studies have reported allodynia in 19% to 37% of patients (08; 19; 15). Accompanying phenomena, such as tearing, eye redness, and nausea, are absent.
Some patients, particularly those with comorbid migraines, have reported precipitating triggers of idiopathic stabbing headaches. Triggers include rapid alterations in posture, physical exertion, bright light, and head motion during migraine attacks (24). However, in most patients, pain is unprovoked.
Ammache and colleagues described a 27-year-old man with primary stabbing headache associated with monocular visual loss and a scintillating scotoma ipsilateral to the pain (02). The patient had a history of migraine with aura.
Ahmed and colleagues reported on 42 children and adolescents with primary stabbing headache (01). The mean patient age was 12 years. Most stabs were located in extratrigeminal regions. The stabbing frequency ranged from daily to monthly. The presentation and nature of primary stabbing headache in children and adolescents vary widely. Two patients in this cohort had a family history of primary stabbing headache.
In another cohort of 77 children and adolescents with primary stabbing headaches, 16.9% were younger than 6 years of age at presentation (37). The location of the headache was frontal in 54.5% of patients and bilateral in 68.8%. One study showed that the features of childhood primary stabbing headache can vary widely (22). Most of the stabs lasted between a few seconds and 30 minutes, and more than half did not meet the ICHD-3 criteria for primary stabbing headache owing to their duration. In addition, this study determined that a high proportion of patients (33%) had associated primary headache, particularly migraines. Furthermore, 72% of patients had almost one episode of episodic syndrome (infantile colic, benign paroxysmal vertigo, motion sickness, recurrent abdominal pain, and cyclic vomiting) (22).
Pediatric primary stabbing headache has several distinct features; attack duration in children shows significant variability, ranging from a fraction of a second to several minutes. Although the ICHD-3 criteria specify stabs lasting up to a few seconds, pediatric cases often present with longer durations. This variability is particularly challenging when interviewing pediatric patients because young children have difficulty distinguishing a single stab from a series of stabs (33).
The quality of pain in pediatric cases may vary, with stabbing pain being the most common, with up to 34% of pediatric patients reporting nonthrobbing pain. This may reflect the difficulty that younger patients have in precisely describing their pain experiences. The intensity typically ranges from moderate to severe, although some pediatric patients describe mild-to-moderate pain that does not affect daily activities. Pain is often unilateral and most commonly localized in the frontal region; occipital pain has also been reported. Associated symptoms, although infrequent, include nausea (in 7% to 14.3% of patients), photophobia and/or phonophobia (in 2.6% to 19% of patients), vertigo (in 1.3% to 8% of patients), and vomiting (in 1.3% to 5% of patients). Some studies have reported a high frequency of periodic syndromes (in up to 47% of patients), primarily cyclic vomiting and recurrent abdominal pain preceding the onset of primary stabbing headache (01; 37; 33).
Several key differences distinguish pediatric primary stabbing headaches from adult cases (33):
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1. Attack duration: Although adult primary stabbing headache typically presents with very brief attacks (3 seconds or less), pediatric cases often report longer durations, up to 15 minutes in some cases. This difference may necessitate reconsideration of the current ICHD-3 diagnostic criteria for pediatric populations. | |
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2. Pain quality: Adults consistently describe stabbing pain, whereas children may report variable pain qualities, including throbbing, reflecting potential developmental differences in pain description capabilities. | |
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3. Location: Adult patients frequently report occipital pain, whereas pediatric patients commonly present with frontal region involvement. | |
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4. Associated features: Adults more commonly report jolts, grimacing, and allodynia, whereas these features are rarely reported in children. However, accompanying symptoms such as nausea, vomiting, and photophobia show similar frequencies across age groups. |
Prognosis and complications
Primary stabbing headache is a benign condition that may recur over time. In patients with infrequent attacks, education on the disorder may be sufficient, and medication may not be necessary. In patients receiving prophylactic treatment, periodic attempts to taper medication are reasonable options for the evaluation of possible remission.
Primary stabbing headache is difficult to predict because of its significant temporal variability. However, Kim and colleagues attempted to do so by prospectively screening and following patients diagnosed with primary stabbing headache in their clinic between June 2015 and March 2016 (15). They identified 65 patients and determined that most followed one of three possible courses: a monophasic (n=31), intermittent (n=17), or chronic (n=12) daily pattern. Patients with a monophasic disease course tended to experience a duration of approximately 9 days, with attacks of greater severity, occurring singly but with multiple attacks daily, side-locked attacks, and responding well to treatment. Women were more likely to experience an intermittent pattern and would experience symptoms for an average for 2 years, with sporadic stabbing headache and variable intensity. Chronic daily primary stabbing headache tended to last for 9 months, was more likely to occur in women, and presented with attacks that were longer-lasting and could change locations. This study was the first to prospectively examine the clinical course of primary stabbing headache, and with the identification of three different typical patterns, future research should help clarify the etiology and optimize treatment strategies.
The natural history of pediatric primary stabbing headaches differs from that of adult cases. Although adults typically show monophasic, intermittent, or chronic daily patterns, pediatric patients often demonstrate more variable courses. The available follow-up data suggest generally favorable outcomes in children, with most patients showing clinical improvements over time. One prospective study showed that a chronic-intermittent course was predominant in pediatric cases (38 of 42 patients) (01). However, long-term natural history data specific to pediatric-onset primary stabbing headache remain limited, thus highlighting the need for further longitudinal studies (33).
Clinical vignette
Patient 1. A 64-year-old man experienced having headaches 5 years prior to presentation. Pain was typically experienced in the left temporal region. It lasted for less than 1 second and was described as a sharp and stabbing pain. Other areas were also affected by the stabs, including the left and right parietal and right occipital regions. He had six to 12 stabs daily. No accompanying symptoms were associated with pain. The physical and neurologic examination results were normal. MRI and MRA of the brain were normal. The patient was indomethacin 25 mg, three times a day, with a significant improvement in headache frequency; however, the medication was not well tolerated. Specific cyclooxygenase-2 inhibitors were administered with good relief.
Patient 2. A 58-year-old woman complained of sudden pain in the right frontoparietal region for 3 weeks. The sudden stabs of pain, lasting approximately 1 minute, were very severe, frustrated the patient, and were followed by vocalization. She reported two to three episodes per day, without autonomic symptoms or any other manifestations but the attacks increased progressively. Indomethacin 25 mg three times per day was initiated, but she still experienced frequent attacks. Celecoxib 100 mg twice daily was prescribed; however, it was ineffective. MRA of the brain showed an aneurysm in the right posterior communicating artery.
Biological basis
Etiology and pathogenesis
Stabbing headaches may occur as primary entities but are often associated with another headache type and can occur secondary to other disorders.
Piovesan and colleagues reported a stabbing headache secondary to cerebrovascular disorders (28). Two women and one man, 76 years of age, 66 years of age, and 72 years of age, respectively, developed headaches within 20 days of stroke. All the patients responded to celecoxib, a cyclooxygenase-2 inhibitor.
The pathogenesis of primary stabbing headache has been postulated to be based on the peculiar characteristics of pain. Hyperexcitability and spontaneous firing of the cervical and trigeminal nerves (which provide sensitive innervation of the scalp), owing to both central and peripheral sensitization mechanisms, may play a major role (16). However, this hypothesis has not been supported by experimental studies. Coexisting autoimmune pathologies that could cause focal demyelination of sensory nuclei in the brainstem (multiple sclerosis, autoimmune vasculitis, and antiphospholipid syndrome) have been inconsistently described in adult patients with primary stabbing headache; however, this association has not been noted in pediatric cases (33).
Epidemiology
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• The reported prevalence of primary stabbing headache ranges from 0.2% to 35%. | |
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• Primary stabbing headache is more common in women in the adult population and equal in children and adolescents. | |
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• Primary stabbing headache is more common in migraineurs. | |
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• Primary stabbing headache may also occur in several other headache disorders, including tension-type headache, hemicrania continua, and cluster headache. |
The reported prevalence of primary stabbing headache ranges from 0.2% to 35% (24). The prevalence of primary and probable primary stabbing headaches varies 2.5% to 10% among children with primary headaches, with notably higher rates among children younger than 6 years of age (37; 22; 33). This wide range in the reported prevalence may reflect both the challenges in diagnosis and the strict ICHD-3 criteria, particularly regarding attack duration in pediatric cases. Studies have suggested that primary stabbing headache is more common in young children, and one study showed a significantly higher prevalence (12.4%) in children younger than 6 years of age than in those greater than 6 years of age (3%) (30).
In one study, 26.7% of neurologists experienced primary stabbing headache over their lifetime, ensuring high diagnostic accuracy (14). In the adult population, primary stabbing headache occurs more commonly in women, with a female-to-male ratio of 1.49-6.6 to 1 (24). There is no gender predominance in children and adolescents (10). However, one study conducted in children and adolescents (median age, 8 years) showed a female predominance, as in adults (22). The mean age of onset was approximately 28 years in a community-based study and 48 years old in a clinical study (44).
Sjaastad and colleagues studied the prevalence of idiopathic stabbing headache in the general population (Vaga study) (39). In that study, conducted in Vaga, Norway, 1838 adults, aged 18 to 65 years, were examined. Jabs and jolts syndrome or idiopathic stabbing headache was diagnosed in 35.2% of the population. The female-to-male ratio was 1.49 to 1. Extracephalic “jabs” were also studied. Three women experienced facial jabs, and one had pain that spread to the head. Four subjects had jabs that occurred randomly throughout the body, including the cephalic area. Pure nuchal jabs were present in 12 patients, 10 of whom were male. The characteristics of extracephalic jabs were not different from the cephalic jabs (40).
Primary stabbing pain occurs more commonly in patients with migraines (32; 27). Primary stabbing headache may also occur in many other headache disorders, including tension-type headache, hemicrania continua, and cluster headache, with a reported prevalence of 21% to 84% in these other disorders (45; 10).
Differential diagnosis
Trigeminal neuralgia involving the first division of the trigeminal nerve is a differential diagnostic possibility. Trigger points, such as brushing teeth, eating, speaking, and the distribution of pain, occur mostly in the maxillary and mandibular trigeminal nerve branches and are notable distinguishing characteristics (ICHD-3).
Patients with (short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms, SUNCT) complained of unilateral headache with frequent (five to 30 times per hour), short-lasting (15 to 60 seconds) attacks of pain in the V1 distribution (ICHD-3). Pain typically occurs in and around one eye and is accompanied by ipsilateral conjunctival injection, lacrimation, or other ipsilateral autonomic symptoms. The presence of autonomic changes was considered diagnostic. The presence of autonomic changes was considered diagnostic. SUNCT and SUNA differ primarily from primary stabbing headaches in the presence of accompanying autonomic symptoms, and the attacks are triggered by cutaneous stimuli on the trigeminal nerves (13).
Attacks of chronic paroxysmal hemicrania have pain characteristics and associated autonomic symptoms and signs similar to those of cluster headache, but the pain attacks are short in duration (ICHD-3). These headaches can be distinguished from primary stabbing headache because bouts of paroxysmal hemicrania generally last 5 and 30 minutes and are associated with autonomic symptoms, such as ipsilateral lacrimation or rhinorrhea.
In occipital neuralgia, pain is distributed within the dermatome of the occipital nerve branch, whereas the pain is more focal in primary stabbing headache (17). Dysesthesia, allodynia, and tenderness in the affected nerve branch are more often associated with occipital neuralgia than primary stabbing headache. Primary stabbing headache and occipital neuralgia can be differentiated diagnostic nerve blocks (17).
Nummular headache is a coin-shaped head pain that ranges 1 to 6 cm in size. The parietal region is the most common site of pain, followed by the occipital region (06). The pain intensity was mild or moderate, and the duration was continuous or intermittent. The most common characteristic of pain is pressure-like pain (44.4%), followed by stabbing pain (16.7%) and burning pain (12.5%) (26). Nummular headache is characterized by a clearly demarcated pain area accompanied by focal tenderness or sensory abnormalities within the pain area in some cases, which distinguishes it from primary stabbing headache (06).
Diagnostic workup
Careful history taking and normal examination are often sufficient to make a diagnosis. However, it is reasonable to perform neuroimaging, either MRI or CT of the brain because encephalitis, neoplasm (cerebral or pituitary), vasculitis (ie, giant cell arteritis), acute thalamic hematoma, cerebral aneurysms, and arteriovenous malformations can present as a stabbing headache (34; 43). Pituitary tumors, meningiomas, and vestibular schwannomas are the most prevalent types of intracranial neoplasms associated with secondary stabbing headache (43). Valenca and colleagues identified that the recent onset of stabbing headache, exclusively unilateral at the same location; crescendo pattern, triggered by head movements; or Valsalva maneuver were red flags for secondary stabbing headache (43). Recommendations for the diagnostic workup of headache with any phenotype, including isolated stabbing headache, should still follow the accepted recommendations to rule out secondary causes when red flags are present (34; 43).
Rampello and colleagues examined 26 patients with stabbing headache and determined that 14 had autoimmune disorders (31). Stabbing headache has been reported in patients with giant-cell arteritis (36). It is reasonable to check the erythrocyte sedimentation rate and C-reactive protein level in patients older than 50 years of age presenting with new-onset stabbing headache. Unless there is other evidence of an autoimmune disorder, there is a low yield to extensively evaluate autoimmune surveys.
When evaluating pediatric primary stabbing headache cases, particular attention should be given to the diagnostic challenges. The attack duration criterion is notably difficult to assess in young children, who may have difficulty distinguishing between single stabs and a series of stabs. Although brain imaging remains normal in most pediatric cases, electroencephalogram (EEG) findings require attention, and studies have reported interictal epileptiform abnormalities in 4% to 40% of cases (37; 33). However, the diagnostic value of EEG remains unclear, and its routine use for diagnosing primary stabbing headaches is generally not recommended. If primary stabbing headache attacks exhibit atypical features (such as longer duration, substantial background pain, or other red flags), neuroimaging becomes mandatory, especially in children younger than 6 years of age (33).
Table 2. Diagnostic Approach to Primary Stabbing Headache
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Initial evaluation: The diagnostic process begins with careful history taking, with a focus on pain characteristics, duration, and pattern recognition. Key elements include: | ||
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- Characteristics and location of pain | ||
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Red flag assessment: Particular attention should be given to features suggesting secondary causes: | ||
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- Recent onset with a fixed unilateral location | ||
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Pattern recognition: Identify the clinical pattern to guide management: | ||
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- Monophasic: Single episode with high intensity | ||
Management
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• Primary stabbing headache is an indomethacin-responsive headache disorder. | |
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• For patients with primary stabbing headache who cannot tolerate or do not respond to indomethacin, alternative treatments are gabapentin, melatonin, celecoxib, other COX-2 inhibitors, onabotulinumtoxin A (BoNTA), topiramate, acetazolamide, and nifedipine. |
Because of the sudden onset and short duration of these attacks, acute treatment is impractical. When attempting to manage patients with frequent attacks of primary stabbing headache, prophylactic medications should be used.
Primary stabbing headache is an indomethacin-responsive headache disorder (24). The vast majority of patients tended to respond quickly to indomethacin 75 to 150 mg/day, administered in divided doses. In most case series, indomethacin yielded 30% to 50% success in achieving complete remission (25; 08; 15). Indomethacin has a few unique properties compared with other nonsteroidal anti-inflammatory drugs (NSAIDs), including the inhibition of nitric oxide release (07), which may explain why some headache disorders including primary stabbing headache respond to this specific NSAID. The adverse events associated with indomethacin include dyspepsia, gastrointestinal bleeding, and renal toxicity.
For patients who cannot tolerate or do not respond to indomethacin, reasonable alternative treatments include gabapentin, melatonin, celecoxib, other COX-2 inhibitors, onabotulinum toxin A (BoNTA), topiramate, acetazolamide, and nifedipine (35; 29; 24). Amitriptyline was successfully administered to two pediatric patients who experienced primary stabbing headache (23).
One systematic review of melatonin for primary headache (not specific for primary stabbing headache) included only four randomized controlled trials with poor methodological quality (351 participants) (20).The results showed that evidence for melatonin as a first-line therapy is lacking, but it is a potential treatment option for difficult headache cases or pediatric primary headaches in the short term (20). Although the structure of melatonin is similar to that of indomethacin, its adverse effects include dizziness, nausea, and vomiting (03). The recommended starting dose of melatonin is 3 mg daily with a possible titration of up to 24 mg (09). Asthma may be a contraindication to melatonin treatment because increased nocturnal serum levels (42).
Treatment strategy based on clinical pattern:
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• Monophasic pattern: Short-term treatment with indomethacin, COX-2 inhibitors, and/or prednisolone | |
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• Intermittent pattern: Preventive treatments including melatonin, gabapentin, topiramate, or amitriptyline | |
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• Chronic pattern: Long-term preventive approaches with regular monitoring and dosage adjustments |
Adjunctive therapies such as lifestyle modifications, stress management, and trigger avoidance may provide additional benefits (15).
Previous pediatric studies explored various treatment options. External hand warming has shown promise as a noninvasive intervention; applying warm mittens for 5 minutes twice daily for 1 month demonstrated a reduction in both the intensity and frequency of primary stabbing headache attacks, with improved daily functioning (11). Melatonin at a dose of 1.5 mg/d (0.07 mg/kg) has shown significant reduction in headache frequency within 2 weeks of treatment, with sustained benefits at 6-month follow-up (33).
Outcomes
Most primary stabbing headache cases are benign and self-limiting (17). Compared to patients with pain in multiple locations, those with pain in fixed locations responded better to treatment (05).
Special considerations
There has been a case report from Colombia of a 7-year-old boy with primary stabbing headache (04). His attacks did not respond to coenzyme Q10 100 mg twice daily but stopped after the initiation of melatonin 1.5 mg at bedtime (0.07 mg/kg). Improvement was seen within the first 2 weeks of starting melatonin. At the 6-month follow-up visit, there was sustained benefit and good adherence, with no adverse effects. The authors concluded that melatonin is a reasonable treatment for primary stabbing headache in the pediatric population.
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Contributors
All contributors' financial relationships have been reviewed and mitigated to ensure that this and every other article is free from commercial bias.
Author
-
Fu-Chi Yang MD PhD
Dr. Yang of National Defense Medical Center in Taiwan has no relevant financial relationships to disclose.
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Editor
-
Shuu-Jiun Wang MD
Dr. Wang of National Yang-Ming University and Taipei Veterans General Hospital received research grants from AbbVie, Lundbeck, Pfizer, Novartis, and Orient Europharma as principal investigator. He received speaker honorariums from AbbVie, Biogen, Eli Lilly, Hava Biopharma, and Pfizer.
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Former Authors
- Ninan Mathew MD
- Robert A Davidoff MD
- Mario F P Peres MD
- Rashmi B HalkerSingh MD
- Jong-Ling Fuh MD
Patient Profile
- Age range of presentation
-
- 13 to 65+ years
- Sex preponderance
-
- unknown
- Heredity
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- none
- Population groups selectively affected
-
- none selectively affected
- Occupation groups selectively affected
-
- none selectively affected
ICD & OMIM codes
- ICD-10
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- Headache: R51
- ICD-11
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- Other primary headache disorder: 8A83
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