What is causing an icy sensation across my skull?

What is an Icy Sensation Across the Skull?

An icy sensation across your skull most likely represents "ice pick headache" (primary stabbing headache), a benign condition characterized by ultra-brief stabs of pain that can feel cold or sharp, typically affecting the frontal or temporal areas. 1

Primary Consideration: Ice Pick Headache

Ice pick headache is a unique headache disorder that presents with:

• Ultra-brief stabs of pain that patients often describe with cold-like sensations 1
• Most common location: frontal or temporal areas of the skull 1
• Prevalence: affects 2-35% of the population, predominantly women 1
• Key distinguishing feature: unlike other brief headache syndromes, it occurs WITHOUT cranial autonomic symptoms (no tearing, eye redness, or nasal congestion) 1
• Associated symptoms: may include nausea, vomiting, photophobia, or dizziness 1

Critical Red Flags Requiring Urgent Evaluation

You must seek immediate medical attention if your icy sensation is accompanied by:

• Sudden onset "thunderclap" pattern - could indicate subarachnoid hemorrhage requiring emergency CT 2
• Fever, neck stiffness, or altered mental status - suggests possible meningitis or intracranial infection 2
• New neurological symptoms: weakness, vision changes, speech difficulties, or coordination problems 3
• Positional component: headache that worsens when upright and improves lying flat (suggests spontaneous intracranial hypotension) 2
• Progressive worsening over days to weeks 3
• Age over 50 with new-onset headache - requires evaluation for temporal arteritis and other serious causes 3

Secondary Causes to Consider

While ice pick headache is typically primary (benign), secondary causes include:

• Neurological conditions: multiple sclerosis, stroke, meningiomas, or herpes zoster meningoencephalitis 1
• Intracranial hypotension: presents with orthostatic headache (worse upright, better lying down) and may have associated symptoms like neck pain, tinnitus, hearing changes 2
• Sinus-related pathology: sphenoid sinusitis can cause skull base involvement with persistent throat pain and vague head sensations 4

When to Pursue Neuroimaging

MRI of the brain without and with contrast is indicated if: 2

• Any red flag symptoms are present
• Symptoms persist or worsen despite treatment
• New neurological deficits develop
• Pattern is atypical for primary ice pick headache
• You are immunocompromised (higher risk for skull base osteomyelitis or fungal infections) 5, 4

Treatment Approach for Primary Ice Pick Headache

First-line treatment: Indomethacin (ice pick headache is one of the "indomethacin-responsive headaches") 1

Important caveat: Up to 35% of patients fail to respond to indomethacin 1

Alternative treatments if indomethacin fails:

• Gabapentin 1
• COX-2 inhibitors 1
• Melatonin 1
• External hand warming 1

Common Pitfalls to Avoid

• Don't dismiss positional headaches: If your icy sensation is worse when standing and better lying flat, this suggests intracranial hypotension requiring specific evaluation with brain MRI looking for venous engorgement, pachymeningeal enhancement, and brain sagging 2
• Don't ignore persistent sinus symptoms: Even asymptomatic sphenoid disease can lead to serious complications including skull base osteomyelitis 4
• Don't assume it's benign in immunocompromised patients: Higher risk for skull base osteomyelitis from sinusitis or otitis externa, particularly with Pseudomonas or Staphylococcus aureus 5

Recommended Next Steps

If no red flags are present: Trial of indomethacin with close follow-up 1

If red flags present or symptoms persist: Obtain MRI brain with and without contrast to exclude secondary causes 2, 3

If positional component exists: Pursue evaluation for spontaneous intracranial hypotension with dedicated brain MRI and possible spinal imaging 2