Hypnic Headache: A Case Presentation Including Polysomnography

Indomethacin-responsive headaches-A narrative review

BACKGROUND

Indomethacin is a nonsteroidal anti-inflammatory drug whose mechanism of action in certain types of headache disorders remains unknown. The so-called indomethacin-responsive headache disorders consist of a group of conditions with a very different presentation that have a particularly good response to indomethacin. The response is so distinct as to be used in the definition of two: hemicrania continua and paroxysmal hemicrania.

METHODS

This is a narrative literature review. PubMed and the Cochrane databases were used for the literature search.

RESULTS

We review the main pharmacokinetic and pharmacodynamics properties of indomethacin useful for daily practice. The proposed mechanisms of action of indomethacin in the responsive headache disorders, including its effect on cerebral blood flow and intracranial pressure, with special attention to nitrergic mechanisms, are covered. The current evidence for its use in primary headache disorders, such as some trigeminal autonomic cephalalgias, cough, hypnic, exertional or sexual headache, and migraine will be covered, as well as its indication for secondary headaches, such as those of posttraumatic origin.

CONCLUSION

Increasing understanding of the mechanism(s) of action of indomethacin will enhance our understanding of the complex pathophysiology that might be shared by indomethacin-sensitive headache disorders.

Hypnic headache in childhood: A literature review

Hypnic headache (HH) is a rare benign disorder described initially by Raskin in 1988. It is characterized by recurrent nocturnal episodes of headache that periodically awaken the sleeping patient and usually occur in the elderly. This review is aimed at describing the clinical features of the HH cases in childhood that have been published in literature so far. Based on a literature search in the major medical databases (LiLacs, SciELO, Bireme, Scopus, EBSCO and PubMed), we have analyzed the case reports on HH in childhood that have been published between 1988 (the first description) and 2014. In this review, we have described five children (3 girls and 2 boys) diagnosed with HH. The average age was 9.0 ± 1.6 years (95% CI 7.6-10.4), ranging from 7 to 11 years. The diagnosis was made 15.8 ± 25.0 months (range 1 to 60 months) after the headache started. Three patients (60.0%) were awakened a few hours after falling asleep. The headache lasted up to 30 min in four (80.0%) patients. The headache was bilaterally localized (4/5; 80.0%), had a throbbing/pulsating character (3/5; 60.0%) and a severe intensity (4/5; 80.0%). The frequency was less than 15 days per month (4/5; 80.0%). The absence of autonomic symptoms was reported by all patients. There was successful treatment with melatonin in 2/5 (40.0%) of the patients. HH is very rare in childhood; its clinical features are inconsistent and still need further evaluation.

Hypnic headache: A review of clinical features, therapeutic options and outcomes

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.

Pathophysiology of hypnic headache

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.

Mechanism of action of indomethacin in indomethacin-responsive headaches

Indomethacin, as a member of the non-steroidal anti-inflammatory drug class, plays a special role in the treatment of headaches. By definition, it is completely efficacious in the treatment of the primary headache disorders paroxysmal hemicrania and hemicrania continua. Therefore, indomethacin is also used as a tool for differential diagnosis in headache clinics. Indomethacin has a clear action as a cyclooxygenase inhibitor. Additional mechanisms and interactions with cell signaling pathways and inflammatory pathways are considered in this article. However, it is not known what mechanism or interaction with pathophysiological mechanisms is the key to indomethacin's specific pharmacology in headache therapy. Focusing on headache therapy, we summarize the current knowledge of pharmacology, treatment options, and recommendations for the use of indomethacin in primary headaches. New findings from the field of headache research, as well as from Alzheimer's disease and cancer research on the pharmacological actions of indomethacin and their potential implications on the pathophysiology of indomethacin sensitive headaches, are discussed.

Hypnic headache

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.

Hypnic headache

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.

Focus on therapy of hypnic headache

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.

Relapsing remitting hypnic headache responsive to indomethacin in an adolescent: a case report

Hypnic headache (HH) is a rare sleep-associated primary headache disorder that usually begins after the age of 60 years. Here we report a 19-year-old male with 4-year history of predominantly left sided HH. He is the youngest person reported who fulfills the IHS diagnostic criteria for HH. The patient had history of relapsing–remitting course. The headache occurred every night at a constant time in each relapse. It was non-throbbing, moderate to severe, for 30 min to 5 h, and usually after 3 h of sleep. The patient showed complete response to indomethacin (75 mg at bedtime). Frequent tapering of indomethacin was required to look for the remission phase.

Clinical Features, Polysomnography and Outcome in Patients with Hypnic Headache

Hypnic headache is rarely reported in Asians, and the proposed International Classification of Headache Disorders (ICHD)-2 criteria have never been field-tested. We studied 17 consecutive Taiwanese patients (M/F: 9/8, mean age at onset 69.6 years) with hypnic headache from a headache clinic. Fifteen patients (88%) reported >15 headache attack days per month. Polysomnography studies done on 11 patients recorded 12 attacks in seven patients: two during rapid eye movement (REM) sleep, three during non-REM sleep and two having both. Five of the seven patients reported their headache profile during polysomnography studies. The clinical course was mostly episodic without recurrence ( n = 9, 53%), followed by relapsing/remitting ( n = 5) and chronic ( n = 3). The ICHD-2 criteria were not fulfilled in 35% (6/17) patients based on patient recall or 60% (3/5) patients based on direct questioning during polysomnography studies. The major reason was the presence of pulsatile rather than dull headache in our patients. Unlike previous studies, our study showed hypnic headache occurred equally in both REM and non-REM sleep, and most patients ran an episodic course.

Secondary "hypnic headache"

Hypnic headache is a rare form of primary headache with attacks occurring exclusively with sleep. As it is typical of the elderly, a wide range of alternative diagnosis must be considered. We present a case report of a 54-year-old woman with unsuspected secondary hypnic headache that was relieved by anti-hypertensive therapy. We reviewed the literature to evaluate the usual diagnostic workup performed in hypnic headache patients. We suggest that 24 h ambulatory blood pressure monitoring may be included in the evaluation of nocturnal headache complaints especially in the elderly, in whom essential hypertension is a very frequent comorbidity.