Editorials

Ice cream headache

All sorts of things can cause headache. For migraineurs, attacks can be provoked by chocolate, cheese, cured meats, or non-food such as stress or changes in sleep habits. Headaches can herald serious neurological disease. Some people have a benign type of headache provoked by coughing or, rarely, by coitus. Many people feel that headaches are caused by eye strain or chronic sinus problems, although probably they are not.

The most common cause of head pain is ice cream, occurring in one third of a randomly selected population.¹ It occurs regardless of whether someone suffers from other types of headache. Children know all about ice cream headache, although I have found that they know it best by the descriptive term "brain freeze."

The pain begins a few seconds after the rapid ingestion of cold foods or beverages and peaks in 30-60 seconds. The pain is usually located in the midfrontal area, but can be unilateral in the temporal, frontal, or retro-orbital region. It is a stabbing or aching type of pain that recedes 10-20 seconds after its onset. Rarely, it persists for two to five minutes.² Studies have been conflicting as to whether ice cream headache is more common in people who experience migraine. Raskin and Knittle found this to be the case, with ice cream headache occurring in 93% of migraine sufferers and in only 31% of controls.³ However, a subsequent study found ice cream headache to be more common in people without migraine.² These inconsistencies may be due to differences in subject selection–the subjects of the first study were drawn from a hospital population, whereas the controls in the second were student volunteers. While ice cream headaches are usually benign and brief, migraines are occasionally triggered by the cold stimulus.²

Ice cream headache has been studied as an example of referred pain.^{4 5} Experimenting on himself, Smith characterised the features of the headache.⁵ Applying crushed ice to the palate, he found that ipsilateral temporal and orbital pain developed 20-30 seconds later. Bilateral pain occurred when the stimulus was applied in the midline. The headache could be elicited only in hot weather; attempts to reproduce the pain during the winter were unsuccessful, even with use of a cold stimulus of the same temperature. Bird et al found a similar relation with respect to site of application of the cold substance and ipsilateral occurrence of the resultant pain.² Some of their subjects also experienced an associated toothache.

The vascular mechanisms invoked to explain the features of migraine were also applied to ice cream headache. Wolf and Hardy characterised cold induced pain in the hand, showing that pulsation in the digital artery diminished in proportion to the intensity of pain and that injection of vasopressin increased the intensity of pain.⁶ Smith observed that the blanching and subsequent redness of the fingers associated with cold induced pain pointed to vascular mechanisms, with pain occurring when the fingers showed erythema and increased blood flow.⁵ A similar progression from constriction to dilatation has been invoked as the mechanism underlying the aura and pulsatile pain phases of migraine. Primary neural mechanisms are now thought to underlie these vascular features.

Raskin has suggested that ice cream headache may represent a model of migraine, in that both encompass disordered thresholds to sensory stimuli.¹ It would be of interest to determine whether antimigraine drugs that modulate serotonergic pathways have any effect on ice cream headache.

No treatment is usually required, and sufferers rarely seek medical attention. Since the posterior aspect of the palate is most likely to produce the referred pain of ice cream headache, avoiding contact of the cold food with this area can effectively eliminate the symptoms. Most people arrive at such preventive measures without the advice of doctors. Ice cream abstinence is not indicated.

Joseph Hulihan, Assistant professor ^a

^a Department of Neurology, Temple University Health Sciences Center, 3401 N Broad Street, Philadelphia, PA 19140, USA

1. Raskin NH. Headache. 2nd ed. London: Churchill Livingstone, 1988.
2. Bird N, MacGregor A, Wilkinson MIP. Ice cream headache–site, duration, and relationship to migraine. Headache 1992;32:35-8. [Medline]
3. Raskin NH, Knittle SC. Ice cream headache and orthostatic symptoms in patients with migraine. Headache 1976;16:222-5.
4. Wolff HG, ed. Headache and other head pain. 2nd ed. Oxford: Oxford University Press, 1963.
5. Smith RO. Ice cream headache. In: Vinken PJ, Bruyn GW, eds. Handbook of clinical neurology. Vol 5. Chichester: John Wiley, 1968:188-91.
6. Wolf S, Hardy JD. Studies on pain–observations on pain due to local cooling and on factors involved in the "cold pressor" effect. J Clin Invest 1941;20:521-33.