Hypnic headache: a rare type of primary headache disorder

ObjectiveHypnic Headache are is a very rare primary headaches that affect the elderly, with an average age of 60 years. Research in the areas of neurophysiology and treatment options for Hypnic Headache are necessary in order to better understand, and improve outcomes for this rare headache disorder.Case reportMr. X is a 70-year-old patient, has been presenting with the complaints of headache during sleep at night for the last 1 year. The Headache started after 3 to 4 hours after falling asleep. Due to headache, he wakes up from sleep around 03:00 to 04:00 am almost every night and his headache persist for 30 to 40 minutes. After waking up from sleep he keeps himself busy with religious activity and the headache gradually resolves. He then goes back to bed again.Mr. X also informed that, the headache is dull in nature and located in left temporo occipital region. It is not associated with photophobia, phonophobia, nausea, vomiting, tearing or discomfort in the leg. He gives no history of early morning headache or day time headache, sleep disorder, snoring or sleep apnea. He has no past history of trauma to the head, fainting attack, unconsciousness, weakness or paralysis of limbs, seizures or non-epileptic seizures. He is an non-smoker, non-alcoholic, non-hypertensive & non-diabetic person.On general examination, his heart rate is 70 beats/min, blood pressure 138/68 mm of Hg. There are no anemia, jaundice or oedema present in him. His both lung fields are clear. On neurological examinations there are nothing abnormality detected. His Serological investigations, CBC (Complete Blood Count) FBS (Fasting Blood Glucose), lipid profile are within normal limit. CT scan of the brain is normal. There are no cerebral atrophy or volume loss compatible with age.Mr. X was treated by several general practitioners with paracetamol, diclofenac sodium, mefenamic acid, tramadol hydrochloride. He used these drugs either singly or in combinations. But with this treatment there were no significant improvement occurs. Mr. X is scared and depressed for his sleep time headache.DiscussionHypnic headache is a very rare headache disorder. It occurs in age groups over 60 years. It is occur at night during in sleep and waking the patient up, hence the name of it “alarm clock headache”. It is commonly unilateral and lasts for 15 minutes to 4 hours. Hypnic headache commonly dull or throbbing in character and does not make the patient restless, unlike in Cluster Headache. After waking up from sleep, most patients engage in some activity. Hypnic headache is not associated with rhinorrhea, tearing and ptosis. Diagnosis is mainly clinical. Secondary causes headache must be excluded. International Classification of Headache Disorders 3rd Edition (ICHD-3)-beta provides diagnostic criteria for hypnic headache. Pathophysiology of hypnic headache is not clearly identified. Usual treatment options of Hypnic headache includes bed time coffee, lithium carbonate, indomethacin. Our patient fulfil all the criteria of Hypnic headache and he fells improvement with Indomethacin 50 mg in devided doses.ConclusionHypnic Headache is a very rare type of primary headache. It should be diagnosed only after other secondary causes of headache have been excluded. Caffeine, lithium carbonate, flunarizine, indomethacin, used to treat the patient of Hypnic Headache. Lack of study and awareness about these disorders can lead to delays in diagnosis and treatment. Clinical trials are needed to find out proper treatment, but it will be difficult to perform because of the rareness of this disorder.

Acoustic neuroma presenting as a hypnic headache

Hypnic headache (HH) is a rare, primary headache syndrome that invariably occurs during sleep and wakes the patient. Acoustic neuroma (AN) is a benign tumour that uncommonly presents with isolated headache. Here, we describe a patient with AN that presented with an HH-like syndrome. A 40-year-old woman presented with 4 months of generalised, throbbing, nocturnal headaches that woke her from sleep. Neurological examination was unremarkable. Retrospectively, she reported a 4-year history of mild, bilateral tinnitus. Neuroimaging demonstrated a large, left-sided AN in the cerebellopontine angle without obstructive hydrocephalus. Gamma knife radiosurgery controlled tumour growth. One year after radiosurgery, she became nocturnal headache-free. AN has not previously been described as presenting with an HH-like syndrome. There are four previous reports of an HH-like syndrome secondary to intracranial masses. In all cases, patients became headache-free following surgery. This advocates for neuroimaging to exclude structural causes.

Comorbid Sleep Disorders and Headache Disorders

Sleep disorders are closely intertwined with different kinds of headache disorders. In some forms of headaches, this association is profound, such as in hypnic headache, where headaches only occur during sleep, or in cluster headache, which has connection to the REM sleep. In other headaches, the association with sleep is more subtle, but nevertheless, very relevant–for instance in migraine, where sleep deprivation or excessive sleep may act as a trigger for migraine, while sleep has a curative effect on the migraine attack. This chapter focuses in the relationship between sleep disorders and headaches focusing on the five primary forms of headaches: migraine, tension-type headache, paroxysmal hemicrania, hypnic headache, and secondary form of headaches such as obstructive-sleep-apnea-related headaches and medication overuse headaches (MOH).

Hypnic headache

Hypnic headache (HH) is a rare primary headache disorder. Its main clinical features are strict sleep-related headache attacks that awaken patients from sleep. As headache attacks often occur at the same time at night, HH has also been referred to as ‘alarm clock headache’. Currently, 225 cases have been reported in the literature. Patients are generally older than 50 years of age at headache onset, but occurrence in younger patients and even children has been described. More women than man are affected. The headache may be bilateral or unilateral. Some migrainous features, such as nausea or photophobia, or mild cranial autonomic symptoms, such as lacrimation, may accompany HH and create diagnostic uncertainty. While most patients display some motor activity during the headache attacks, the agitation and motor restlessness that is characteristic of cluster headache does not appear. The pathophysiology of HH is still enigmatic. Hypothalamic involvement has been considered on the basis of the circadian rhythmicity, relationship with sleep, and imaging evidence of a decrease in grey matter volume within the posterior hypothalamus. Caffeine, lithium carbonate, and indomethacin may be effective for the prevention of attacks, but randomized, placebo-controlled trials are not yet available.

Headaches in the elderly

There is a non-controversial definition about who is an elderly patient. The age group above 85 years is the fastest growing segment in the total population. Persisting pain is not rare in this patient group and the prevalence for persisting pain is 40–79%. Migraine prevalence declines gradually after the age of 40 years, but even in the age group of 60 years and older up to 5% complain of migraine and in some patients the symptoms change towards more tension type-like headaches. Tension-type headaches are thought to be the most prevalent primary headaches in the elderly, with a 1-year prevalence of about 36%; secondary headaches often present as tension type-like headaches. A typical age-bounded headache is hypnic headache, which is only seen in patients older than 55 years of age. In the treatment of headaches in the elderly, the pharmacokinetic changes with age should be considered; the distribution volume and elimination kinetics are different in the elderly. Therefore, treatment should be initiated as ‘slow and low’.

The prevalence of hypnic headache in Iceland

Objective To determine the prevalence of hypnic headache. Background The exact prevalence of hypnic headache is unknown since there are no published population-based prevalence studies. Methods This study was a pilot for the SAGA cohort study, a population-based study on life stressors and various indices of health. Of 1398 invited adults, 921 (66%) participated; 402 men (average age 45.6 years, SD 13.2) and 519 women (52.6 years, SD 11.1). Subjects answered a headache questionnaire including a screening question for hypnic headache. “Do you have a headache that occurs only during sleep and causes wakening?”. Diagnosis of hypnic headache was made by clinical interview using ICHD-3 criteria. Results Among 921 participants, six screened positive for hypnic headache, of those two 0.22% (95% CI 0.06–0.79%) had probable hypnic headache and none had definite hypnic headache. Conclusion Confirming that hypnic headache is rare, these data suggest a 0.22% prevalence of probable hypnic headache.