primary stabbing headache is a short duration headache disorder that is characterized by brief paroxysms of sharp head pain often located in the first division of the trigeminal nerve , occurring at an irregular frequency , lacking any accompanying symptoms , and not attributable to any underlying cause . stabbing headache has also been reported to occur as a symptom of , or in association with , a variety of underlying secondary disorders , including giant cell arteritis [ 2 , 3 ] , pituitary tumors , meningiomas , ocular pathology , ischemic stroke [ 6 , 7 ] , cavernous hemangioma of the frontal bone , and varicella zoster meningoencephalitis . stabbing headache has not been reported to manifest as a direct consequence of a small well - circumscribed acute brain lesion , and its pathophysiology remains elusive . herein , a lesional cause of stabbing headache , a small acute thalamic hematoma , is presented . a 95-year - old right - handed caucasian woman presented to our emergency department with the sudden onset of a constellation of spontaneous neurological symptoms . she first noted repetitive , sharp , 12  s paroxysms of pain in strictly the right frontal and supraorbital region , occurring dozens of times per hour but at irregular and unpredictable frequencies . her pain was unaccompanied by photophobia , phonophobia , cranial autonomic symptoms , or any visual changes . she did not identify any triggers and tactile stimulation of any area of the head or face did not provoke the pain . these attacks continued until she finally fell asleep in the hospital 12  h later , and upon awakening 6  h later , did not recur . minutes after the head pain onset , she noted mildly slurred speech , which also resolved by the following morning , and upon attempting to ambulate she felt very imbalanced , which persisted for several days . her past medical history included hypertension , hyperthyroidism , gastroesophageal reflux , osteoarthritis , and a left intertrochanteric femoral fracture sustained after a fall , which was surgically repaired 4  months previously . postoperatively she developed cholangitis from choledocholithiasis , an acute pulmonary embolism , and paroxysmal atrial fibrillation , for which she was treated with intravenous antibiotics and placed on long - term anticoagulation . she had no history of any primary headache disorder , denied ever experiencing any focal neurological symptoms . her medications included warfarin , fosinopril , omeprazole , metoprolol , digoxin , and methimazole . she lived with her husband and was a retired school teacher . on review of systems , for several months she had ongoing right upper quadrant pain and occasional nausea that had been attributed to choledocholithiasis . she denied jaw claudication , episodes of visual loss , myalgias , or neck pain . her general medical examination revealed a well - appearing woman with normal vital signs , and only mild right upper quadrant tenderness . on neurological examination , deep tendon reflexes were 1 + in the arms , trace at the knees , and she lacked ankle jerks . she had a white blood cell count of 12,000/l , a total bilirubin of 2.3  mg / dl , a direct bilirubin of 1.2  mg / dl , an alkaline phosphatase of 560 u / l , a sgot of 341  u / l , and a sgpt of 292  u / l . noncontrast computed tomography of the head revealed a rounded hyperdense lesion in the left lateral thalamus abutting the posterior limb of the internal capsule , consistent with an acute small hemorrhage , along with multiple subcortical lacunes and white matter ischemic changes ( fig .  1 ) . the hematoma volume was estimated to be 0.12  cm using the abc/2 method .fig . 1axial noncontrast computed tomography of the brain revealed an acute , rounded hyperdense lesion in the region of the left thalamus and likely abutting the posterior limb of the internal capsule ( white arrow ) , corresponding to a small acute hemorrhage axial noncontrast computed tomography of the brain revealed an acute , rounded hyperdense lesion in the region of the left thalamus and likely abutting the posterior limb of the internal capsule ( white arrow ) , corresponding to a small acute hemorrhage the patient was administered fresh frozen plasma and vitamin k to reverse her coagulopathy and ultimately had an endoscopic retrograde cholangiopancreatography , where numerous gallstones were removed . the patient was ultimately discharged to a short - term rehabilitation facility for her imbalance and deconditioning . the correspondence of the acuity of the clinical syndrome with the radiographic demonstration of an acute hematoma strongly supports its causality , although the lack of magnetic resonance imaging makes the exclusion of other acute lesions slightly less definitive . a fixed site of stabbing headache may signify an underlying symptomatic cause of the disorder ,   as was the case with this patient . although a stabbing pain character of headache is not uncommon in association with acute cerebrovascular disease , the diagnosis of stabbing headache has not been well described in this population . in a large prospective series of over 2,000 patients with acute ischemic stroke where headache details were captured at stroke onset , 20% of the patients described their pain character as stabbing , although the diagnosis of stabbing headache was not mentioned . pareja and colleagues mentioned the onset of stabbing headache in a patient with an ischemic stroke to the parietal lobe , but did not describe its laterality and relationship to the site of the stabbing head pain . piovesan and colleagues reported the occurrence of stabbing headache in a delayed fashion after an ischemic stroke in three patients who all likely sustained acute middle cerebral artery territory infarctions . regarding hemorrhagic stroke , in a large series of 90 intracranial hemorrhage survivors , six patients experienced stabbing headache de novo after intracranial hemorrhage , only one of whom had no premorbid headache history . acute thalamic hematomas in particular can lead to headache over half the time , but similar to other deep structures do not lead to headache nearly as often as hemorrhage in the posterior fossa or lobar structures . in this patient , stabbing headache resulted from an acute parenchymal brain lesion in the thalamus , a location vital to the processing of pain . more specifically , the location of the hematoma may have encompassed the ventral posteromedial nucleus of the thalamus , a relay center for sensory input from the trigeminal system . the association of the pain strictly occurring in the right trigeminal distribution with a lesion in the corresponding left thalamus is intriguing . some authors have proposed the disorder results from spontaneous activation of peripheral nerve branches in the trigeminal or upper cervical distribution [ 14 , 15 ] . another theory is that patients with stabbing headache have segmental and fleeting disinhibition of central pain pathways [ 14 , 15 ] . perhaps in cerebrovascular disease , such disinhibition occurs in an acute fashion in those patients with contralateral pain to the site of infarction or hemorrhage . in stroke patients with ipsilateral stabbing headache this report demonstrates an association of an acute thalamic lesion with stabbing headache occurring in the contralateral trigeminal distribution . particularly in an elderly patient or individual taking anticoagulants , a small thalamic hemorrhage should be considered in the differential diagnosis of new - onset stabbing headache , even when fleeting .
stabbing headache can be encountered in both primary and secondary forms , but has been infrequently reported among patients with stroke , and is not known to be associated with a small well - circumscribed brain lesion . a 95-year - old woman taking warfarin presented with the sudden onset of stabbing headache strictly in the right frontal and supraorbital regions , along with gait imbalance and dysarthria . 
 neuroimaging revealed a small left thalamic hematoma . 
 this association of an acute thalamic lesion with stabbing headache in the contralateral trigeminal distribution is discussed , along with a brief review of stabbing headache occurring in cerebrovascular disease .