Pathophysiology Of Hypnic Headache Research Articles

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.

Sleep disorder-related headaches.

Migraine with and without aura, cluster headache, hypnic headache, and paroxysmal hemicranias are each reported as intrinsically related to sleep. Chronic migraine, chronic tension-type headache, and medication overuse headache may cause sleep disturbance. Otherwise, both headache and sleep disorder may be manifestations of a same systemic dysfunction. There is a vicious cycle linking sleep disorders and migraine. The poor quality or poor duration of sleep could be a trigger of migraine attack and migraineurs with poor sleep reported a higher headache frequency. Moreover, coping behaviors of migraineurs (e.g., going to sleep early to relieve migraine attacks) can be factors precipitating and perpetuating sleep disturbances themselves. During cluster headache, patients report a poor quality of sleep correlated with the amount of daylight. In particular, it was demonstrated that melatonin levels have influences on cluster headache attacks. Concerning the pathophysiology of hypnic headache, it has been hypothesized a possible role of obstructive sleep apnea in triggering nocturnal attacks: an increased number of apnea episodes has been reported in hypnic headache patients, but a lack of a temporal correlation of headache attacks with the drop of oxygen saturation has been observed. Tension-type headache is the most common headache with sleep dysregulation (lack of sleep or oversleeping) frequently reported as a triggering factor for acute attacks: management of sleep disturbances seems crucial in this form of headache.

Hypnic headache: pathophysiology, differential diagnosis and management

Headache is one of the commonest reasons for patients to see a GP and to consult a neurologist. Hypnic headache (HH) is a rare type of short-lasting primary headache. It is sometimes called ‘alarm clock headache’ or ‘clockwise headache’, as it tends to wake people up from sleep around the same time each night—from a couple of nights a week to every single night. It was first described by Neil Raskin, a US neurologist, in 1988, and the diagnostic criteria have been further refined in the updated version of the International Classification of Headache Disorders (ICHD-3ß). This article will discuss the pathophysiology of HH, its clinical features and presentation, expanding on differential diagnosis and management suggestions, with reference to a patient case report. The aim is to draw nursing attention to this rare but often debilitating headache condition.

No Pattern Alteration in Single Nocturnal Melatonin Secretion in Patients With Hypnic Headache: A Case-Control Study.

To investigate headache-related serum melatonin levels and melatonin excretion rhythmicity in patients with hypnic headache (HH). Strict sleep dependency of headache attacks is a pathognomonic feature of HH. Changes in melatonin levels, a marker for circadian rhythm, are assumed to play a pivotal role in the pathophysiology of HH. Serum melatonin levels were acquired in nine patients with HH and nine age- and gender-matched healthy controls over a 20-hour time period (12 pm, 4 pm, 7 pm, 10 pm, time of headache, and 8 am). No significant changes of melatonin levels could be detected comparing HH patients and healthy controls. Melatonin excretion rhythmicity was not significantly altered in patients with HH (Mean melatonin level in ng/mL ± SD, patients vs controls at 12 pm: 21.5 ± 9.5 vs 13.6 ± 6.3 [P = .077], 4 pm: 18.4 ± 8.4 vs 14.0 ± 4.7 [P = .222], 7 pm: 19.4 ± 5.1 vs 15.1 ± 4.5 [P = .094], 10 pm: 59.5 ± 45.0 vs 29.4 ± 12.7 [P =.136], headache time: 96.9 ± 68.3 vs 49.1 ± 22.8 [P = .94], and 8 am: 31.6 ± 18.3 vs 26.7 ± 15.6 [P = .489]). This study is not able to confirm a significant role of melatonin concentration changes in the pathophysiology of HH and vetoes that melatonin deficiency plays a major role in the pathophysiology of the disorder.

A Case of Hypnic Headache Responded to Indomethacin

Received April 30, 2013 Revised June 18, 2013 Accepted June 18, 2013 Address for correspondence Jae Wook Cho, MD Department of Neurology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20 Geumo-ro, Mulgeum-eup, Yangsan 626-770, Korea Tel: +82-55-360-2122 Fax: +82-55-360-2451 E-mail: sleep.cho@gmail.com Hypnic headache (HH) is a primary headache disorder occurring exclusively during sleep in the elderly. Although pathophysiology of HH is still unknown, the association with chronobiological perspective and rapid eye movement sleep has been suggested. Lithium has been reported to be the most effective drug for HH. However, its usage may be limited because of its toxicity. Indomethacin could be alternative treatment option, which has better safety profile. We report a case of HH, which was successfully treated with indomethacin. J Korean Sleep Res Soc 2013;10:31-33

An unusual case of hypnic headache ameliorated utilizing a mandibular advancement oral appliance

AbbreviationsHH Hypnic headacheTMJ Temporomandibular jointBMI Body mass indexMAD Mandibular advancement applianceCH Cluster headacheOSA Obstructive sleep apneaCPAP Continuous positive airway pressureSCN Suprachiasmatic nucleusPAG Periaqueductal graySRBDs Sleep-related breathing disordersIntroductionHypnic headache (HH), first reported by Raskin [1], is arare and recurrent benign headache disorder that occursexclusively during sleep and usually presents after the ageof 60. Generally described as a primary headache of theelderly [2], the attacks are usually of short duration(30 min) and awaken the patient at a constant time eachnight. According to the International Classification ofHeadache Disorders, second edition (ICHD-2) [3], HHmust fulfill the following criteria:1. A dull headache fulfilling criteria 2–4:2. Develops only during sleep and awakens the patient3. At least two of the following characteristics:(a) Occurs >15 times per month(b) Lasts ≥15 min after waking(c) First occurs after the age of 50 years4. No autonomic symptoms and no more than one ofnausea, photophobia or phonophobia5. Not attributed to another disorderIn a case series, HH has been reported to account for0.07% of all headache patients [4]. The pathophysiology ofhypnic headache is yet to be fully elucidated, but due to itscircadian nature as well as its reported responsiveness tolithium [1], a disturbance of chronobiologic rhythmsappears to be putative. Previous reports of utilizing positiveairway pressure in hypnic headache patients have proven tobe inconclusive [5–8].The relationship between headache and sleep haspreviously been reported in the literature [9]. As hypnicheadaches will only occur during sleep, it potentiallyprovides us with the most robust insight into the commonetiologic mechanisms of these two entities. Additionalprimary headaches that occur during nocturnal sleep aremigraine, cluster headache, and chronic paroxysmal hemi-crania [10]. Other disorders that should be considered withheadaches that awaken us are obstructive sleep apnea(OSA) or sleep hypoxia/hypercapnia, restless leg syndromeor periodic limb movements during sleep, psychophysio-logic insomnia, chronic pain syndrome or fibromyalgia, ordepression/anxiety [10]. All should be considered in thedifferential until proven otherwise. A comprehensivehistory is necessary to accurately diagnose these headachedisorders. Headaches associated with OSA or sleep hypox-ia/hypercapnia are classified as secondary headaches orheadaches attributed to a disorder of homeostasis [11].Morning headaches will occur at a rate of 18–74% ofpatients with OSA [12]. About 40% of patients withinsomnia have headaches in the morning [13]. It has beenreported that 65% of sleep bruxism (SB) patients reportedfrequent headaches [14, 15]. However, laboratory studieshave demonstrated that most morning headaches are notdirectly correlated with SB [16, 17].

Hypothalamic gray matter volume loss in hypnic headache

Hypnic headache (HH) is a rare primary headache disorder characterized by strictly nocturnal headache attacks that mostly occur at the same time at night. The pathophysiology of this disease is poorly understood, but hypothalamic involvement was suspected as the hypothalamus represents the cerebral management center of sleep regulation and pain control. Fourteen patients with HH and 14 age-matched and gender-matched healthy controls were investigated using magnetic resonance imaging-based voxel-based morphometry. We detected gray matter volume decrease in the posterior hypothalamus of HH patients. Additional gray matter decrease was observed in brain areas known to be associated with cerebral pain processing, including the cingulate cortex, operculum, and frontal lobe, as well as in the temporal lobe. Our data confirm the hypothesized involvement of the posterior hypothalamus in the pathophysiology of HH and emphasize the importance of this structure for sleep regulation and pain control.

Serial polysomnography in hypnic headache

Hypnic headache (HH) is a rare primary headache disorder characterized by strictly sleep-related headache attacks. Most patients are over the age of 50 and usually awake at the same time at night with dull bilateral head pain. The pathophysiology of this headache disorder is still enigmatic but association with rapid eye movement (REM) sleep and sleep-disordered breathing (SDB) has been suggested. Six patients with HH according to the current International Classification of Headache Disorders (ICHD-II) criteria (code 4.5) were investigated. Serial polysomnography (PSG) was performed in each patient for four consecutive nights. A total of 22 HH attacks were recorded from all patients during PSG. Six of the monitored headache attacks arose from REM sleep; 16 attacks, however, arose from different non-REM (NREM) sleep stages. Five patients showed an increased apnoea/hypopnoea index (>5), indicating obstructive sleep apnoea (OSA) on some but not the majority of nights. Headache onset and occurrence of SDB were not temporally connected. This prospective study shows that the onset of HH was not associated with sleep stage. These results contradict the current belief that REM sleep and SDB play a crucial role in the pathophysiology of HH.

Hypnic headache: an update

Hypnic headache (HH) is a rare sleep-associated primary headache disorder, usually affecting aged people, first described by Raskin in 1988. The headache attacks, single or multiple in one night, occur exclusively during sleep and tend to present at a consistent time each night, sometimes during a dream. Compared to the original description, newly reported cases have expanded the clinical spectrum of the disorder to include unilateral forms (about 40%, half of which are side-locked), forms with a longer duration (up to 3 h) and cases with onset in juvenile/adult age. The male predominance found in Raskin's series has not been confirmed by subsequent observations. To date the reported F/M ratio is 1.7/1. Pain is of severe intensity in less then one-third of cases and mild-moderate in about two-thirds. The location of pain is fronto-temporal in over 40% of cases; headache is throbbing in 38% of cases, dull in 57% and stabbing in less than 5%. Nausea is reported in 19% of cases; photophobia, phonophobia or both are present in 6.8%. Mild autonomic signs (lacrimation, nasal congestion, ptosis) may rarely be present. In 2004, HH was included in Group 4 of the International Classification of Headache Disorders-II (Other primary headaches). Sufficient evidence, mainly from polysomnographic studies, indicates that HH is a primary rapid eye movement (REM) sleep-related headache disorder of chronobiological origin. Lithium, melatonin, indomethacin and caffeine at bedtime are among the most effective therapeutic options. The pathophysiology of HH is still unclear. Available data allow speculation that, in predisposed subjects, an age-related impairment of suprachiasmatic nucleus could cyclically activate a disnociceptive mechanism leading to both a sudden awakening and headache. The mechanism may be precipitated by neurophysiologic events such as the strong reduction of firing occurring in the dorsal raphe nucleus during a REM sleep phase.