Case Study—Hypnic Headache Syndrome
By Lawrence Newman, MD, Director, Headache Institute, Roosevelt Hospital Center, New York, NY, and Associate Clinical Professor of Neurology, Albert Einstein College of Medicine, Bronx, New York
The Case
Mary is a 68-year-old woman who developed headaches approximately five years ago. These headaches involve her entire head, are throbbing and fairly severe. Each headache lasts one to two hours and then spontaneously resolves even without treatment. The headaches are not associated with any other symptoms.
Mary has seen many doctors over the years for these headaches, and has had numerous neurological examinations, blood tests and three MRIs of her brain. Everything has always been normal. She is desperate to “get to the bottom” of these headaches because, curiously, they only strike her at night, always between 1 and 3 A.M. She hasn’t had a good night’s sleep in five years.
Discussion
In general, headaches beginning for the first time after the age of 50 are a cause for concern. In an older person, new-onset headaches may be the result of a serious disorder such as a brain tumor, stroke, or inflammation of the arteries of the head (a condition called giant cell arteritis). They, therefore, require extensive investigation. Luckily for Mary, these tests have been done and no serious cause of the headache was uncovered. Also, the fact that Mary has had a nightly headache for the past five years without any change in the pattern usually suggests a benign cause.
There are a number of primary (benign) headaches that may have their onset during sleep, most notably cluster and migraine headaches, but these headaches usually begin much earlier in life. Only one specific headache disorder is characterized by the features that Mary describes. Hypnic headache syndrome is a rare, sleep-related, primary headache disorder that usually begins after 50 years of age. It was first described in 1988; more than 90 cases have subsequently been reported. The condition is more common in women.
Hypnic headaches occur at a consistent time each night, usually between 1 and 3 A.M., and may, in rare instances, occur during a daytime nap. In fact, because of this unique pattern, this syndrome has been referred to as the “alarm-clock” headache. The headaches begin abruptly, are diffuse and throbbing, and spontaneously resolve in 15 to 180 minutes. The pain in hypnic headache is usually localized in the front of the head but occasionally affects the sides of the head or the entire head. On rare occasions, the headache only affects one side of the head.
The number of headache attacks varies from patient to patient. The majority of patients suffer from four or more attacks per week; more than half have daily attacks. There are usually no other symptoms, although nausea and light and sound sensitivity may be present.
The treatment of this syndrome begins with reassurance as these headaches, although painful and disruptive of sleep, are nonetheless benign. The medication most often recommended to treat the condition is lithium carbonate, but it is often poorly tolerated. (Lithium side effects included thirst, tremor, increased urination, and confusion.) Other agents that have been reported to effectively treat hypnic headache include bedtime doses of caffeine (40-60 mg tablet or as a cup of coffee) and indomethacin.
Although headaches beginning for the first time after age 50 may be attributable to a serious cause, hypnic headache syndrome is actually a benign headache disorder that affects older patients. The disorder is notable for its propensity to strike only while the patient is asleep.
The article says 90 cases. Is that at your hospital? I have the same headaches. Some weeks only one other Time’s. Three or for days in a row. I fine certain foods seem to aggravate the condition. Hot or cold compress on forehead seem to help but it changes with each headache.
Hi- This is an older article, but the expert was referring to the number of reported cases in the U.S. in 2007.
Thank you for your article. I too have been dealing with the symptoms of a Hypnic headache as described in your case study of Mary, the 68 year old woman. I have probably had these for 10 or so years, seen neurologist, ENT, internist, etc., none of which have diagnosed or treated these headaches. It has been – I believe mistakenly – diagnosed as migraines and/or stress. I also suspect a CSF leak or AVM’s however the hypnic is the closest description.
This is intense, unbearable headaches that start out as mild in early morning (1:30am) and do not go away unless I get up, walk around, have a cup of coffee, maybe take an NSAID though I try to avoid if possible. I might go back to bed at 5:30am if I can get it to go away but it does not go away on its own.IT DOES NOT GO AWAY ON ITS OWN.
I have read about other symptoms which may or may not be related but think important to mention.
Sometimes in day, clear sinus drainage, sometimes mild tinnitis. at night. . The pain starts in one side of the head, my right sinus and works its way behind the eye to the temple, and to the side and back of my head. It is not so much a throb as it is increasingly intense pressure and pain. (I should mention that I have had sinus surgery in past for deviated septum and several possible concussions, some clear sinus fluid drainage on one side, thus my suspicion for CSF)
Do you have a punch list of all possible symptoms as many times, one forgets to mention something that could help in identifying, properly testing, preventing, and treating these headaches.
And most importantly, do you have a doctor in Atlanta, GA that believes and specializes in these unusual and misdiagnosed headaches.
Thank you,
Karen Johnston
Hi…where can I go in NYC that treat hypnic headaches?
Hi Karen, i have been plagued with the same issues. 6 years of neurologists, 3 MRI’s, multi drugs which I do not wish to take, physio, chiropractors, ajovy/emgalia injections, still on botox every 3 months, the list goes on.
My headaches are every single night between 10.30 and 11.30pm but I also get them if lying, about 3pm, at a 45 degree angle. As well as botox I am living on Imigran nasal spray.
The only person that is helping me with all this is my Dr, last night we spoke on the phone and she mentioned Hypnic headaches and caffeine. Straight away I googled and have found this site, reading about Mary I am saying this is me. Now I know what it is, interesting that 6 neurologists have never mentioned this type of headache !! The sad part is there is no cure.
At least I am not alone.
Tricia