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Ferretti A, Velardi M, Fanfoni C, Di Nardo G, Evangelisti M, Foiadelli T, Orsini A, Del Pozzo M, Terrin G, Raucci U, Striano P, Parisi P. Pediatric hypnic headache: a systematic review. Front Neurol 2023; 14:1254567. [PMID: 37638182 PMCID: PMC10457117 DOI: 10.3389/fneur.2023.1254567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 08/02/2023] [Indexed: 08/29/2023] Open
Abstract
Introduction Hypnic headache (HH) is a primary headache, and it is considered a rare condition in children. The underlying mechanisms of HH are not yet fully understood. This systematic review aims to provide a comprehensive description of the clinical features of all published cases of pediatric HH. It will also discuss the differences in headache features between children and adults, the increased diagnostic sensitivity of the new diagnostic criteria (ICHD-3), potential pathophysiological hypotheses explaining the higher incidence in adults, differential diagnoses, and therapeutic options for children. Methods A systematic search was conducted to identify and analyze articles reporting cases of HH in patients under the age of 18. The search was performed in major medical databases including Cochrane Library, EBSCO, Embase, Medline, PubMed, Science Direct, Scopus, and Web of Science. The search covered the period from 1988 to April 2023. Relevant studies were screened for eligibility, and data extraction was performed using a standardized approach. Results Seven children with HH were included in the analysis. The mean age of onset for headache attacks was 10 ± 4.3 years (range 3-15 years). The average time from the start of headaches to diagnosis was 15.8 ± 25.0 months (range 1-60 months). Headache features in children differed from those observed in adult HH patients. Children experienced throbbing/pulsating pain, while adults reported dull/pressure-like pain. Children also had lower frequency and shorter duration of attacks compared to adults. The use of ICHD-3 criteria appeared to be more sensitive and inclusive for diagnosing HH in children compared to the previous ICHD-2 criteria. The association of headache attacks with sleep suggests that HH may be a primary disorder with a chronobiological origin. Hypothalamic dysfunction and melatonin dysregulation, which are more prevalent in older individuals, could potentially explain the higher incidence of HH in adults. Other primary headaches and secondary causes should be ruled out. Melatonin prophylactic therapy may be considered for pediatric patients. Discussion Further evaluation of the clinical features of HH in children is needed. The development of specific diagnostic criteria for pediatric cases could improve diagnostic rates and enhance the management of children with HH.
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Affiliation(s)
- Alessandro Ferretti
- Pediatrics Unit, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, S. Andrea Hospital, Rome, Italy
| | - Margherita Velardi
- General and Emergency Department, Bambino Gesù Children’s Hospital, Istituto di Ricerca e Cura a Carattere Scientifico, Rome, Italy
| | - Claudia Fanfoni
- Pediatrics Unit, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, S. Andrea Hospital, Rome, Italy
| | - Giovanni Di Nardo
- Pediatrics Unit, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, S. Andrea Hospital, Rome, Italy
| | - Melania Evangelisti
- Pediatrics Unit, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, S. Andrea Hospital, Rome, Italy
| | - Thomas Foiadelli
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alessandro Orsini
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Marco Del Pozzo
- Pediatrics Unit, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, S. Andrea Hospital, Rome, Italy
| | - Gianluca Terrin
- Department of Mother and Child, Gynecological and Urological Sciences, Faculty of Medicine and Dentistry, Sapienza University of Rome, Rome, Italy
| | - Umberto Raucci
- General and Emergency Department, Bambino Gesù Children’s Hospital, Istituto di Ricerca e Cura a Carattere Scientifico, Rome, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Pasquale Parisi
- Pediatrics Unit, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, S. Andrea Hospital, Rome, Italy
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Lindner D, Scheffler A, Nsaka M, Holle-Lee D. Hypnic Headache - What do we know in 2022? Cephalalgia 2023; 43:3331024221148659. [PMID: 36786376 DOI: 10.1177/03331024221148659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND Hypnic Headache, also known as "alarm clock headache", is a rare primary headache disorder. It is characterized by frequently recurring headache attacks, which only develop during sleep, especially nighttime sleep. OBJECTIVE This article gives a narrative review on the current knowledge about Hypnic Headache with a focus on secondary Hypnic Headache. METHODS Based on literature research, using Pubmed and Google Scholar, latest case reports, studies, and systematic reviews about Hypnic Headache were analyzed and summarized focusing on therapeutic options and causes of secondary Hypnic Headache. CONCLUSION Hypnic Headache mainly occurs in elderly patients. However, younger patients and children may also suffer from Hypnic Headache. Many different causes of secondary Hypnic Headache are described in the literature and ought to be ruled out before diagnosing primary Hypnic Headache. The pathophysiology of primary Hypnic Headache remains unclear, but a dysfunction of the hypothalamus seems to play a key role.
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Affiliation(s)
- Diana Lindner
- Department of Neurology, Westgerman Headache Center Essen, University Hospital Essen, Essen, Germany
| | - Armin Scheffler
- Department of Neurology, Westgerman Headache Center Essen, University Hospital Essen, Essen, Germany
| | - Michael Nsaka
- Department of Neurology, Westgerman Headache Center Essen, University Hospital Essen, Essen, Germany
| | - Dagny Holle-Lee
- Department of Neurology, Westgerman Headache Center Essen, University Hospital Essen, Essen, Germany
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Fortes YML, Erudilho E, Silva TSD, Souza WPDO, Silva-Neto R. Secondary hypnic headache: A literature review in the last 34 years. HEADACHE MEDICINE 2022. [DOI: 10.48208/headachemed.2022.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Introduction: Hypnic headache is a rare primary headache disorder that occurs during sleep. Its pathophysiology is uncertain, but hypothalamic dysfunction is hypothesized. It is usually a primary headache, but it can have secondary causes.
Objectives: We aimed was to review articles published in the last 34 years on hypnic headache and analyze secondary cases.
Methods: Based on a literature search in the major medical databases and using the descriptor “hypnic headache” we included articles published between 1988 and 2020. Of the 359 patients found, only 18 met the inclusion criteria and were analyzed.
Results: We found 18 patients (6 men and 12 women) with secondary hypnic headache. The mean age of patients was 58.7±15.0 years, ranging from 20 to 84 years. The causes of hypnic headache were attributed to cranial vascular disorder (five), to non-vascular intracranial disorder (six), to a substance or its withdrawal (three) and to disorder of homoeostasis (four).
Conclusions: Although most cases of hypnic headache are primary, some symptomatic cases are described in the literature.
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Ceronie B, Green F, Cockerell OC. Acoustic neuroma presenting as a hypnic headache. BMJ Case Rep 2021; 14:14/3/e235830. [PMID: 33687931 PMCID: PMC7944972 DOI: 10.1136/bcr-2020-235830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
- Bryan Ceronie
- Cardiology, West Middlesex University Hospital, Isleworth, London, UK .,Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Frederick Green
- Ear, Nose and Throat Surgery, Barts Health NHS Trust, London, UK
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Silva-Néto RP, Soares AA, Peres MFP. Hypnic Headache Due to Hypoglycemia: A Case Report. Headache 2019; 59:1370-1373. [PMID: 31498893 DOI: 10.1111/head.13627] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2019] [Indexed: 01/24/2023]
Abstract
Hypnic headache (HH) is a rare primary headache disorder and pathophysiology is still poorly understood. It is considered a chronobiological disorder in almost all published cases. Few secondary cases have been described so far. We report a case of a 64-year-old woman presenting headaches exclusively during sleep and fulfilling the diagnostic criteria for HH, but a 72-hour glucose monitoring showed hypoglycemia episodes related to the onset of headaches. To our knowledge, this is the first report of symptomatic HHs associated with hypoglycemia and it suggests direct evidence of HH due to a metabolic disorder.
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Tariq N, Estemalik E, Vij B, Kriegler JS, Tepper SJ, Stillman MJ. Long-Term Outcomes and Clinical Characteristics of Hypnic Headache Syndrome: 40 Patients Series From a Tertiary Referral Center. Headache 2016; 56:717-24. [DOI: 10.1111/head.12796] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Nauman Tariq
- Michigan Headache & Neurological Institute; Ann Arbor MI USA (N. Tariq); the Cleveland Clinic, Cleveland, OH, USA (E. Estemalik, B. Vij, J.S. Kriegler, M.J. Stillman); Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA (S.J. Tepper)
| | - Emad Estemalik
- Michigan Headache & Neurological Institute; Ann Arbor MI USA (N. Tariq); the Cleveland Clinic, Cleveland, OH, USA (E. Estemalik, B. Vij, J.S. Kriegler, M.J. Stillman); Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA (S.J. Tepper)
| | - Brinder Vij
- Michigan Headache & Neurological Institute; Ann Arbor MI USA (N. Tariq); the Cleveland Clinic, Cleveland, OH, USA (E. Estemalik, B. Vij, J.S. Kriegler, M.J. Stillman); Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA (S.J. Tepper)
| | - Jennifer S. Kriegler
- Michigan Headache & Neurological Institute; Ann Arbor MI USA (N. Tariq); the Cleveland Clinic, Cleveland, OH, USA (E. Estemalik, B. Vij, J.S. Kriegler, M.J. Stillman); Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA (S.J. Tepper)
| | - Stewart J. Tepper
- Michigan Headache & Neurological Institute; Ann Arbor MI USA (N. Tariq); the Cleveland Clinic, Cleveland, OH, USA (E. Estemalik, B. Vij, J.S. Kriegler, M.J. Stillman); Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA (S.J. Tepper)
| | - Mark J. Stillman
- Michigan Headache & Neurological Institute; Ann Arbor MI USA (N. Tariq); the Cleveland Clinic, Cleveland, OH, USA (E. Estemalik, B. Vij, J.S. Kriegler, M.J. Stillman); Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA (S.J. Tepper)
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Liang JF, Wang SJ. Hypnic headache: A review of clinical features, therapeutic options and outcomes. Cephalalgia 2014; 34:795-805. [DOI: 10.1177/0333102414537914] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Hypnic headache (HH), first reported in 1988, is a rare sleep-related headache disorder. In 2013 a new diagnostic criteria was proposed for HH in the International Classification of Headache Disorders, the third version beta (ICHD-3β). Purpose This review aimed to update the clinical characteristics, therapeutic options and clinical outcomes in patients with HH and also validate the new diagnostic criteria. Methods Based on a literature search in the major medical databases, we analyzed all case reports or case series on HH that have been published since the first description by Raskin. Except for symptomatic patients, all reported patients were included regardless of which diagnostic criteria were adopted. Four studies that reported the field-testing results of the ICHD-2 criteria were selected to validate the new ICHD-3β criteria. Results In total, 250 adult and five childhood patients are described in this review. The majority of patients were elderly and their ages of onset were typically more than 50 years old (92%). Approximately 7.7% of patients had some trigeminal autonomic features, which are not permitted in the ICHD-3β criteria. Compared with the ICHD-2 criteria, the diagnostic rate under the new criteria increased from 65% to 85% in recently reported cases. Randomized control trials both for acute and prophylactic treatment are lacking. Based on observational studies, the most effective acute treatment is caffeine and prophylactic medications in use are lithium, caffeine and indomethacin. Without treatment, the disease course is usually protracted but spontaneous remission did occur in 12 patients (4.8%). In those treated with prophylactic agents, no recurrence was noted in 43% of patients, even following withdrawal of medication. Conclusions The new ICHD-3β criteria are more sensitive and exhaustive for HH than the ICHD-2 criteria. Prophylactic treatment provides better outcomes; however, randomized controlled studies for treatment are needed to further verify the efficacy of the different drugs.
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Affiliation(s)
- Jen-Feng Liang
- School of Medicine, National Yang-Ming University, Taiwan
- Department of Neurology, Neurological Institute, Taiwan
- Department of Medical Education, Taipei Veterans General Hospital, Taiwan
| | - Shuu-Jiun Wang
- School of Medicine, National Yang-Ming University, Taiwan
- Department of Neurology, Neurological Institute, Taiwan
- Institute of Brain Science, Taiwan
- Brain Research Center, National Yang-Ming University, Taiwan
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Abstract
Background Hypnic headache (HH) is a rare primary headache disorder that is characterized by strictly sleep related headache attacks. Purpose The underlying pathophysiology of HH is mainly enigmatic but some clinical characteristics such as circadian rhythmicity and caffeine responsiveness may point toward possible underlying mechanisms. Method Current studies that deal with the pathophysiology of HH are summarized. Data on cerebral imaging, sleep, electrophysiology studies, effectiveness of drugs, and symptomatic headache types are discussed to illuminate underlying pathophysiologic mechanisms. Conclusion HH can be clearly differentiated by its clinical presentation as well as imaging and electrophysiological study results from other primary headaches such as migraine or cluster headache. The underlying pathophysiology is still enigmatic but a hypothalamic involvement seems to be likely.
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Affiliation(s)
- Dagny Holle
- Department of Neurology and Westgerman Headache Center Essen, University Duisburg-Essen, Germany
| | - Steffen Naegel
- Department of Neurology and Westgerman Headache Center Essen, University Duisburg-Essen, Germany
| | - Mark Obermann
- Department of Neurology and Westgerman Headache Center Essen, University Duisburg-Essen, Germany
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Vollbracht S, Grosberg BM. Unusual Short-duration Primary Headaches. Headache 2013. [DOI: 10.1002/9781118678961.ch20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
Background Hypnic headache (HH) is a rare primary headache disorder that is characterised by strictly sleep-related headache attacks. Purpose Because of the low prevalence of this headache disorder, disease information is mainly based on case reports and small case series. This review summarises current knowledge on HH in regard to clinical presentation, pathophysiology, symptomatic causes and therapeutic options. Method We review all reported HH cases since its first description in 1988 by Raskin. Broadened diagnostic criteria were applied for patient selection that slightly deviate from the current ICHD-II criteria. Patients were allowed to describe the headache character to be other than dull. Additionally, accompanying mild trigemino-autonomic symptoms were permitted. Conclusions Mainly elderly patients are affected, but younger patients and even children might also suffer from HH. Headache attacks usually last between 15 and 180 minutes, but some patients report headache attacks up to 10 hours. Almost all patients report motor activity during headache attacks. Cerebral MRI and 24-hour blood pressure monitoring should be performed in the diagnostic work-up of HH. Other primary headache disorders such as migraine and cluster headache may also present with sleep-related headache attacks and should be considered first. Caffeine taken as a cup of strong coffee seems to be the best acute and prophylactic treatment option.
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Affiliation(s)
- Dagny Holle
- Department of Neurology, University Duisburg-Essen, Germany
| | - Steffen Naegel
- Department of Neurology, University Duisburg-Essen, Germany
| | - Mark Obermann
- Department of Neurology, University Duisburg-Essen, Germany
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Göbel A, Heinze A, Göbel H. [Different headache forms of chapter 4 of the International Headache Classification]. Schmerz 2012. [PMID: 23183994 DOI: 10.1007/s00482-012-1264-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Chapter 4 of the International Classification of Headaches contains a group of clinically very heterogeneous primary headache forms. Little is known about the pathogenesis of these headache types and therapy is usually based on isolated case reports and uncontrolled studies. The forms include primary stabbing headache, primary cough headache, primary exertional headache, primary headache associated with sexual activity, hypnic headache, primary thunderclap headache, hemicrania continua and the new daily persistent headache. Some of these headache forms may be of a symptomatic nature and require careful examination, imaging and further tests. Primary and secondary headache forms must be carefully distinguished.
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Affiliation(s)
- A Göbel
- Schmerzklinik Kiel, Heikendorfer Weg 9-27, 24149, Kiel, Deutschland
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Abstract
Sleep and trigeminal pain processing share several common pathways with respect to neurotransmission and functions of distinct brain areas. In this review, the role of the most important brain stem and midbrain regions for this link is discussed. The central structure involved in both headache and sleep is the hypothalamus in which the orexinergic neurons originate. These neurons project to the periaqueductal grey and are probably the anatomic and physiological link between headache and sleep. Another relevant system for this interrelationship is the melatonin metabolism. However, basic research in this field is still very preliminary and a holistic hypothesis on how sleep physiology impacts headache and vice versa is still missing.
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Affiliation(s)
- Stefan Evers
- Department of Neurology, University of Münster, Münster, Germany
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Abstract
Hypnic headache is a rare short-lasting headache occurring exclusively during sleep in the elderly population. First described in 1988 by Raskin, this headache syndrome was adopted by the International Classification of Headache Disorders in 2004 within the "other primary headache" group (code 4.5). Since then, additional case reports and case series were published and provided data to best understand hypnic headache. This review highlights new findings to discuss the relevance of actual diagnostic criteria and the treatment approach of this nocturnal headache syndrome. We also consider hypnic headache pathophysiology that remains speculative.
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Affiliation(s)
- Michel Lanteri-Minet
- Département d'Evaluation et Traitement de la Douleur du Pôle de Neurosciences Cliniques, du CHU de Nice, Hôpital Pasteur, France.
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Abstract
During the 14th International Headache Congress the results of several innovative studies that contribute to our understanding of headache pathophysiology and treatment were presented. Here we summarize work expected to contribute substantially to understanding headache mechanisms, while an accompanying manuscript summarizes presentations regarding the treatment of headache. This manuscript highlights research on mechanisms of photophobia and phonophobia, pharmacologic inhibition of cortical spreading depression, a proposed mechanism by which oxygen effectively treats cluster headache, identification of functional and structural aberrations in people with hypnic headache, and research on functional imaging markers of a migraine attack.
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Affiliation(s)
- Todd J Schwedt
- Washington University Headache Center, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA
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Lisotto C, Rossi P, Tassorelli C, Ferrante E, Nappi G. Focus on therapy of hypnic headache. J Headache Pain 2010; 11:349-54. [PMID: 20585827 PMCID: PMC3476352 DOI: 10.1007/s10194-010-0227-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Accepted: 05/18/2010] [Indexed: 11/08/2022] Open
Abstract
Hypnic headache (HH) is a primary headache disorder, which occurs exclusively during sleep and usually begins after 50 years of age. There are no controlled trials for the treatment of HH. We reviewed all the available papers, including 119 cases published in literature up to date, reporting the efficacy of the medications used to treat HH. Acute treatment is not recommended, since no drug proved to be clearly effective and also because the intensity and the duration of the attacks do not require the intake of a medication in most cases. As for prevention, a wide variety of medications were reported to be of benefit in HH. The drugs that were found to be effective in at least five cases are: lithium, indomethacin, caffeine and flunarizine. Lithium was the most extensively studied compound and demonstrated to be an efficacious treatment in 32 cases. Unfortunately, despite its efficacy, significant adverse effects and poor tolerability are not rare, mainly in elderly patients. Many patients reported a good response to indomethacin, but some could not tolerate it. Caffeine and melatonin treatments did not yield robust evidence to recommend their use as single preventive agents. Nevertheless, their association with lithium or indomethacin seems to produce an additional therapeutic efficacy. A course of lithium should be tried first, followed 3–4 months later by tapering. If headache recurs during tapering, a longer duration of therapy may be needed. If lithium treatment does not provide a significant response, indomethacin can be commenced as second-line approach. If these treatments prove to be ineffective or poorly tolerated, other agents, such as caffeine and melatonin, can be administered.
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Affiliation(s)
- Carlo Lisotto
- Headache Centre, Department of Neuroscience, S. Vito al Tagliamento Hospital, Pordenone, Italy
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Caminero AB, Martín J, Sánchez del Río M. Secondary hypnic headache or symptomatic nocturnal hypertension? Two case reports. Cephalalgia 2010; 30:1137-9. [DOI: 10.1111/j.1468-2982.2009.02011.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- AB Caminero
- Sección de
Neurología, Hospital Ntra. Sra. de Sonsoles, Avila, Spain
| | - J Martín
- Servicio de
Nefrología, Hospital Ntra. Sra. de Sonsoles, Avila, Spain
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Abstract
We report a case of secondary hypnic headache in a patient with a haemangioblastoma of the cerebellum. The number of secondary cases is steadily increasing in the medical literature and magnetic resonance imaging of the brain should be considered mandatory after arriving at a presumptive diagnosis.
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Affiliation(s)
- William J Mullally
- Department of Neurology, Harvard Vanguard Medical Associates and the Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kathryn E Hall
- Clinical Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
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