Hypnic Headache Successfully Treated With Botulinum Toxin Type A

Hypnic Headache - What do we know in 2022?

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.

Beyond chronic migraine: a systematic review and expert opinion on the off-label use of botulinum neurotoxin type-A in other primary headache disorders

Introduction: Botulinum neurotoxin type-A (BoNTA) is licensed for the treatment of chronic migraine (CM), but it has been tested off-label as a therapeutic choice in other primary headaches (PHs). We aimed to provide a systematic review and expert opinion on BoNTA use in PHs, beyond CM.Areas covered: After providing an overview on PHs and mechanism of BoNTA action, we report the results of a systematic review, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations, of BoNTA therapeutic trials in PHs beyond CM. Studies and results were reviewed and discussed, and levels of evidence were graded. We also collected data on relevant ongoing trials.Expert opinion: Although there are contradictory findings on PHs other than CM, BoNTA may represent a therapeutic option for patients who do not respond to conventional prophylactic treatments. Based on limited available evidence, BoNTA may be considered in refractory tension-type headache, trigeminal autonomic cephalalgias, primary stabbing headache, nummular headache, hypnic headache, and new daily persistent headache, after the primary nature of cephalalgia has been documented and other drugs have failed. Experienced physicians in BoNTA treatment are required to guide the therapeutic protocol for each patient to optimize good and safe outcomes.

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.

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.

Occipital nerve stimulation for medically refractory hypnic headache

OBJECTIVE

Hypnic headache is a rare, primary headache disorder that exclusively occurs regularly during sleep. We present a case of hypnic headache successfully managed with occipital nerve stimulation.

MATERIALS AND METHODS

A 64-year-old female presented with a four-year history of a right occipital headache that regularly awakened her from sleep. The headache, which was dull and throbbing, would awaken her regularly at 4:00 am, five hours after bedtime at 11:00 pm. No photophobia, nausea or vomiting, lacrimation, or other autonomic symptoms were present. The headache was refractory to various medical treatments, including indomethacin, flunarizine, propranolol. She underwent a trial of occipital nerve stimulation with a lead electrode using a medial approach.

RESULTS

During the ten-day trial stimulation, she reported almost complete relief from hypnic headache. Chronic occipital nerve stimulation replicated the trial results. The attacks of hypnic headache recurred in one year with loss of stimulation-induced paresthesia; a subsequent x-ray showed electrode migration. After revision of the electrode to the original location, the effectiveness of the occipital nerve stimulation against hypnic headache was achieved again, and this effect has been consistent through 36 months of follow-up.

CONCLUSION

Occipital nerve stimulation was effective in a patient with chronic, refractory hypnic headache.

Treatment of miscellaneous idiopathic headache disorders (Group 4 of the IHS classification)--report of an EFNS task force

BACKGROUND AND PURPOSE

Certain miscellaneous idiopathic headache disorders, which are regarded as entities, are grouped in Chapter 4 of the International Classification of Headache Disorders. Recent epidemiological research suggests that these headache disorders are underdiagnosed.

OBJECTIVES

To give expert recommendations for the different drug and non-drug treatment procedures of these different headache disorders based on a literature search and on consensus of an expert panel.

METHODS

All available medical reference systems were screened for all kinds of clinical studies on these headache disorders. The findings in these studies were evaluated according to the recommendations of the EFNS resulting in level A, B or C recommendations and good practice points.

RECOMMENDATIONS

For all headache disorders, acute and prophylactic drug treatment is recommended based on case series and on expert consensus. Furthermore, recommendations for the differential diagnoses are given because these headache disorders can also present with a symptomatic form. The most effective drug for the majority of these headache disorders is indomethacin, mostly applied as long-term or short-term prophylaxis.

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.

Hypnic headache

Hypnic headache is a rare primary headache disorder that is characterized by exclusively sleep-related headache attacks in patients usually beyond 50 years of age. Only 174 cases have been reported in the literature so far. Owing to its low prevalence, clinical features and therapeutic options, as well as underlying pathophysiologic mechanisms, are widely unknown or being controversially discussed. The association of hypnic headache with rapid-eye movement sleep was strongly contradicted in recent articles, while an association with hypothalamic dysfunction is thought to be one important pathophysiological mechanism. Common acute, as well as prophylactic, treatment is caffeine intake, either in the form of a cup of coffee or a caffeine tablet. Lithium, indomethacin and melatonin were promoted as potent medical treatments, while almost every other drug commonly used to treat headache or other pain syndromes was reported to be effective in single case reports on hypnic headache.

Hypothalamic gray matter volume loss in hypnic headache

OBJECTIVE

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.

METHODS

Fourteen patients with HH and 14 age-matched and gender-matched healthy controls were investigated using magnetic resonance imaging-based voxel-based morphometry.

RESULTS

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.

INTERPRETATION

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.

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.