Severe, Frequent, Stabbing Headaches

You’ve heard how severe “ice pick headaches” can be. There are other primary headache disorders that resemble Primary Stabbing Headache, with a few differences. These disorders fall into the category of Trigeminal Autonomic Cephalalgias (TAC) along with Cluster Headache, Hemicrania Continua, and Paroxysmal Hemicrania. This category is different than migraine because these disorders all share a common set of symptoms not usually seen in Migraine.


All TACs have symptoms of involuntary triggering of the autonomic nervous system. Patients with a TAC headache disorder will experience severe headache pain plus:

  • Lacrimation (tears or watery eyes)
  • Conjunctival injection (redness of the eye)
  • Rhinorrhea (runny nose)
  • Nasal congestion
  • Eyelid edema (swelling)
  • Facial sweating
  • Facial skin flushing
  • Sensation of fullness of the ear
  • Miosis (unusually small pupils)
  • Ptosis (eyelid drooping)

Short-lasting neuralgiform headache attacks fall into 2 sub-types: SUNCT and SUNA.

  • SUNCT stands for short-lasting neuralgiform headache attacks with conjunctival injection (eye redness) and tearing.
  • SUNA stands for short-lasting neuralgiform headache attacks with cranial autonomic symptoms.

They are basically identical except that a diagnosis of SUNCT requires BOTH eye redness and tearing. SUNA is diagnosed if ANY autonomic symptoms are present.

Both SUNCT and SUNA present with these symptoms

  • At least 20 attacks
  • Moderate to severe pain in or around the eye, temple, or anywhere on the head or face that follows the trigeminal nerve
  • Attacks last from 1 second to 10 minutes
  • Attacks are stabbing (not throbbing like migraine or pressure like tension-type headaches)
  • Attacks occur at least once a day and can occur dozens of times per hour

Either disorder can be classified as chronic or episodic

  • Episodic SUNCT/SUNA occurs when patients have at least 2 cycles that last from 7 days up to 1 year with remission times of more than 1 month between cycles.
  • Chronic SUNCT/SUNA occurs when patients have attacks without remission or when remission lasts less than 1 month for at least a year.


Because attacks are so frequent and short-lasting, it can be difficult to treat each attack. Triptans are ineffective and other oral medications simply take too long to kick in. Plus, trying to treat that many attacks each month would automatically put someone at risk for Medication Overuse Headache.

That’s why it’s so important to find a good preventive treatment to reduce the number and severity of attacks. The trouble is – that’s not always so easy. Unlike Hemicrania Continua, SUNCT and SUNA do not respond to indomethacin. Often carbamazepine or lamotrigine are tried first. If either of those are ineffective, gabapentin or topiramate may be tried. IV lidocaine can bring temporary relief, but can be a useful tool. If a patient responds well to IV lidocaine, then they have a good chance of responding to one of these anti-seizure medications.


Both SUNCT and SUNA are rare headache disorders and are often comorbid with Trigeminal Neuralgia or Cluster Headache.

Getting the right diagnosis

It's easy to dismiss a runny nose and watery eyes as allergies. When these symptoms occur along with severe, stabbing headache pain, allergies just might not be the culprit. If you are experiencing sharp, stabbing headache pain with allergy-like symptoms, please get it checked out by a headache specialist to rule out SUNCT or SUNA before just assuming they are “ice pick headaches” or allergies.

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