16 Symptoms You Cannot Ignore

Dangerous Headaches are usually headaches of recent onset in someone who has never previously had a headache. 

Dangerous Headaches sometimes happen to people with Migraine or Tension-Type Headache. The difference is that dangerous headaches are new and very different.  

Before you start looking for answers to your headache problem you need to know that you are safe.

The 16 Patterns that could indicate Dangerous Headaches

Most people with these present to an emergency room as it is obvious to them that something is not right.  (The overall chance of a dangerous cause is in brackets).

1. Sudden Severe Headache Out of The Blue: Thunderclap Headache (10-15%)
2. New Onset Headache with a New Onset of Fever (5%)
3. Headache with Progressive Neurological Symptoms or Signs (5-10%)
4. Postural Type (Orthostatic) (30%)
5. Exercise Induced (20%)
6. Cough Induced (10-20%)
7. With Pulsatile Tinnitus (20%)
8. New onset With a Previous History of Cancer (10%)
9. With Known HIV Infection (10%)
10. Headache with loss of menstrual cycle / loss of libido (5%)
11. New onset in your 50s or over with weight loss and scalp tenderness (30%)
12. A New Headache In Wintertime or after Electricity Black Out (10%)
13. Cluster Headache of recent onset(<5%)
14. Bouts of severe facial pain called Trigeminal Neuralgia (10%)
15. Severe headache with a Body Mass Index over 40 (5-10%)
16. A Chronic Headache that is completely out of control (0.05%)

Always remember to seek medical advice for symptoms causing you concern.

Headaches lasting more than 6 months are unlikely to be dangerous headaches.

Dangerous Headaches will have significant features mentioned in this guide.

1. Sudden Severe Headache Completely Out of The Blue- Thunderclap Headache

Thunderclap Headache is severe and appears suddenly.   At it’s worst from the very start, it comes out of nowhere.  Until that point you will never had anything as bad ever.

Thunderclap Headache usually affects the whole head.  It does not build up over hours like a Migraine.  The pain is at its peak within 2 seconds ….1….2……BOOM!

A Thunderclap Headache will persist for several hours before settling down.

The most common headache mistaken for Thunderclap Headache is a brief, severe, sharp pain called Ice-Pick Headache.  Ice-Pick Headache usually happens in or around one eye.  It is away as quick as it came, and is an example of a ‘Neuralgic’ Pain.

The most important question to ask is “from the start of the headache until it reached its worst – how long did that take?”

Doctors miss Thunderclap Headache when the onset isn’t discovered as sudden and severe.  This can lead to serious harm, so always be clear about the exact onset of  a new headache.

What Causes Thunderclap Headache?

Thunderclap Headache is due to ‘Subarachnoid Haemorrhage’ in about 10% of people.  Most people with ‘Subarachnoid Haemorrhage’ have had a ‘Berry Aneurysm’.  A Berry Aneurysm is a weakness in the wall of an artery which bursts to cause bleeding. 

Thunderclap Headache needs IMMEDIATE medical advice.  Normally a CT Brain Scan is needed as soon as possible.  If a CT Brain Scan is normal you need a Lumbar Puncture Test , and even an angiogram or venogram test of brain blood vessels.

Causes of Thunderclap Headache – the longest list on the planet (Links to Facebook)

What is the most important thing to know about Thunderclap Headache?

The time from start to maximum pain.

The Difference between Thunderclap Headache and Ice-Pick Headache

Ice-pick Headaches also cause sudden severe headache that is at its worst from the start.  However, Ice-pick Headache usually affects a small part of the head only – most commonly in or around one eye – and only lasts a few seconds. 

Ice-Pick Headaches are very common – maybe 20,000 people per million get Ice-Pick Headaches each year, compared to 400 people per million with Thunderclap Headache.

Repeated Episodes of Thunderclap Headache

It is possible for Thunderclap Headache to return repeatedly over several weeks or months.  When it returns, emotion, exertion or a specific scenario like having a very hot bath may be the reason.  Sexual Activity causes repeated attacks of Thunderclap Headache. 

‘Reversible Cerebral Vasoconstriction Syndrome (RCVS)’ is the most likely cause of repeated Thunderclap Headache.  RCVS makes brain arteries go into spasm, and the spasm causes the sudden severe pain.  Up to 60% of people with Thunderclap Headache may have some form of Reversible Cerebral Vasoconstriction Syndrome.

One-Sided Thunderclap Headache

A sudden severe headache on one side of the head needs investigation.  The cause depends on the location of the pain and examination findings.  A sudden onset of severe pain in one eye or one side of the forehead can indicate a Carotid Artery Dissection.   

Carotid Dissection usually causes the upper eyelid on the same side as the pain to drop a couple of millimetres.  You can check if an eyelid position is old or new by comparing with old photographs.

People may describe a ripping sensation in the head or neck at the start of the pain.  The pain that persists is often throbbing in nature and feels really severe. 

If a similar pain occurs in the back of the head, then the artery at the base of the skull called the Vertebral Artery may have torn – called Vertebral Artery Dissection. 

Most people with dissection make a full recovery – the artery heals itself up.

However, a tear in the lining of an artery can lead to a stroke.  Some types of dissection can also lead to a rupture of the artery causing brain haemorrhage. 

Sudden, one-sided headache, followed by symptoms of weakness, speech loss or visual loss could be due to a stroke.  Suspected stroke needs immediate medical attention.

Many people with sudden, one-sided headache have normal tests.  In this situation the most likely cause is pain referred from the jaw joint (TMJ) or Upper Cervical Spine.  Pain referred from the upper cervical spine is called Cervicogenic Headache and some people call it Occipital Neuralgia.

2. New Onset Headache with New Onset Fever

One of the most feared dangerous headaches is suspected Meningitis.  In Meningitis there is a new onset headache with fever. For every 10 people with Meningitis, 9 will have ‘Viral Meningitis’ and 1 will have a much more dangerous cause called ‘Bacterial Meningitis’.

There is a 10% risk of meningitis being found in someone attending an Emergency Room with new onset of headache and fever.

30% of survivors of Bacterial Meningitis will have a significant neurological problem, and the overall risk of death is about 10%.  Bacterial Meningitis must be treated as an emergency, as early treatment reduces the risk of harm.

The Headache of Meningitis

In Viral Meningitis the headache usually follows a day or two of feeling run down – like you have a viral illness.  The pain in the head can build up at the same time as the main illness.  Alternatively you experience a much more sudden build up of headache after a few days of feeling run down and hot.

Neck stiffness is also a common symptoms that accompanies the headache. 

At the same time, you will feel very hot and may have other symptoms of a viral illness eg aching limbs, sore throat, cough, nasal congestion. 

The headache of Bacterial Meningitis is a progressive headache.  However most people with Bacterial Meningitis develop the headache over a few hours before feeling so ill that they get help.  Half of people with Bacterial Meningitis will be in hospital within 24 hours of their first symptom.   

Bacterial Meningitis is a much more severe and dangerous headache than Viral Meningitis and needs immediate antibiotic treatment. 

95% of people confirmed as having bacterial Meningitis have at least 2 of the following 4 symptoms:

headache; neck stiffness; fever; altered mental status.   

Other important symptoms that can appear alongside the headache of Bacterial Meningitis include: weakness, rigors, extreme exhaustion and a new rash.

People with any type of Meningitis can get a sudden severe Thunderclap Headache – this is why a Lumbar Puncture should be performed when investigating a new sudden severe headache.

What does the Headache of Meningitis Feel Like?

The pain of Meningitis is very difficult for the patient to describe – it is just very severe and will feel like the worst headache they have ever had.  It can described as a pressure – like the head wants to burst.  It can also be a severe all-over throbbing pain.

Almost everyone with Meningitis will say that it is sore to look at light – called Photophobia.  The pain of Meningitis can sound like Migraine, but in Meningitis there is a fever present.

People with Meningitis do not get significant relief from standard painkillers – at which point medical advice is usually sought.  Usually the whole head is involved – it is not normally a one-sided pain.

How can I tell the difference between Migraine and Meningitis?

Telling the difference between Migraine and Meningitis is difficult.  Many people with Migraine will have had the experience of being admitted to hospital to have tests for Meningitis. 

Both types of headache are severe, throbbing and you want to avoid light.  Vomiting occurs in both.

In someone with a previous history of Migraine it is hard to know if this is Migraine or Meningitis.  If in doubt a doctor will usually manage the headache as Meningitis until they can rule it out.  The short answer is that there is no easy way to tell the difference – it’s usually safety first.  In Migraine the tests will be normal.

Systemic Illness Headache – The Most Common Cause of Headache and Fever

Most people with new onset of headache and new onset of High Temperature have an infection which will go away itself.  This is called ‘Systemic Illness Headache’.

A common cause would be Influenza (The ‘Flu’), various types of pneumonia or upper respiratory tract infection.  The headache will usually feel like a pressure or throbbing pain.  The clue that it is not Migraine or Tension-Type Headache is that the high temperature alongside the pain.  As the fever settles, so does the headache.

As many as 80% of people with this type of infection of the nervous system will report mild headache during their illness – and tests will not show evidence of meningitis.

3. Headache with Progressive Neurological Symptoms or Abnormal Neurological Signs

A focal neurological symptom is a symptom caused by abnormal activity in the nervous system. 

Blurred vision, double vision, tingling or numbness, weakness of face, arm or leg, vertigo, and loss of speech are focal symptoms.

A focal neurological sign is an abnormality of body structure or function observed by a doctor (or optician) during a neurological or eye examination. 

How the face muscles, arms or legs move, or how the reflexes react are also examples of neurological signs.

Changes in patterns of eye movement, the shape of the pupils, position of the eyelids, the shape or colour of the optic disc or retina are also signs. A doctor or optician would identify these eye signs. 

A neurological and eye examination is a very important part of assessing a person with headache.  Any new headache accompanied by abnormal neurological signs is potentially one of the dangerous headaches.

What pattern of Headache with Focal Neurological Symptoms is dangerous?

Dangerous Headaches have progressive neurological symptoms.  The neurological symptoms start slowly – maybe over several weeks and continue to get progressively worse.  With each passing week there is worsening loss of vision, loss of speech, weakness or confusion.

A progressive focal symptom like this can be a symptom of Brain Tumour or an infection of the brain called encephalitis.  A blocked vein within the head – called cerebral venous sinus thrombosis, can also present as one of the dangerous headaches.

The headaches experienced by people with Brain Tumours, encephalitis or blocked veins in the head can all sound just like Tension-Type Headache – eg an intense pressure, and will sometimes throb.  Nausea or intolerance of light can sometimes occur. 

Migraine with Aura: The Most Common Cause of Headache and Focal Neurological Symptoms

About 12% of all adults will experience Migraine.  About 1 in 5 people with Migraine will experience Migraine Aura.  This means that 1 person in every 40 will experience Migraine Aura (here’s the arithmetic:  12.5% time 20% = 2.5% or 1 in 40).   

In Migraine Aura there is a gradual build up of visual loss, abnormal sensation, weakness or speech disturbance over 5-20 minutes, which can last another 20-120 minutes before going away completely.

About 1 person in 5 with Migraine will experience Migraine Aura.  Migraine Aura can happen just before the pain of a Migraine Headache, but can also happen on its own between Migraine Headaches (called Isolated Migraine Aura).

Migraine Aura is due to a protective electrical change in the surface of the brain called ‘Cortical Spreading Depression’.  This protective response spreads slowly across the surface of the brain and is now understood as the reason for Migraine Aura.   

Migraine Aura with Headache is not dangerous.  However, someone who only ever gets Migraine Aura and NEVER has any headache will need investigated further. Migraine Aura on its own – especially if it appears in later life – 60’s or older – can be a symptom of a focal brain disease such as a minor stroke. 

How do Migraine Aura and Brain Tumour differ?

The difference between is not the nature of the headache – it’s the nature of the focal neurological symptoms that come along with the headache.

Migraine Aura will build up over minutes, last minutes to an hour or two, then settle.  The focal neurological symptoms of a brain tumour will start over days and build to their worst over several weeks.  When examined, a doctor will identify abnormal signs, or be sufficiently concerned about the progression of symptoms that tests are arranged.

New Onset Headache with Short Lived Focal Neurology

Some people will develop a focal symptom a bit like this: the hand or foot will start to claw or tighten, and then within a few seconds start to shake or stiffen.  The shaking or stiffness can spread from foot to hand, or hand to foot or even to one side of the face.  This pattern of movement would make me suspicious of a partial epileptic seizure.

A partial epileptic seizure, of new onset always needs investigated.  In adults a partial epileptic seizure happening for the first time has a 10% risk of an underlying serious problem such as a Brain Tumour.

Everyone with focal epileptic seizures needs to seek medical advice to get treatment to reduce the risk of further epileptic seizures.

What do Brain Tumour Headaches Feel Like?

The classic Brain Tumour headache is due to the fact that a large Brain Tumour will start to take up too much room inside the head.  This creates a high pressure situation which stretches pain-sensitive structures like the lining of the brain or blood vessels in the brain.  The jargon term doctors use is an ‘SOL” – a Space-Occupying-Lesion.

A classic ‘SOL’ headache is actually very rare.

People who have Brain Tumours and Only have Headache.

Only 2% of people with Brain Tumours will have headache – AND ONLY HEADACHE – by the time they are diagnosed.  

Even then most Brain Tumour Headaches sound like Tension-Type Headache.

In Brain Tumour Headache other focal symptoms start to appear within about 8-10 weeks.  Long standing headaches with no other symptoms and normal neurological and eye examinations are not caused by Brain Tumours. 

In people with Brain Tumours there is a significant clue on neurological examination – swelling of the back of the eye, or an abnormal neurological sign affecting eye movement, balance, speech or strength.

Classic Brain Tumour Headaches are Rare

Only 1/16 Brain Tumours which present with headache have classic ‘SOL’ (Space Occupying Lesion) Headache.  A classic ‘SOL’ headaches is a headache that wakens from sleep and causing unprovoked vomiting. 

As the day goes on – when you are up and about – the headache improves, only for it to be repeated the next morning. 

The reason a classic ‘SOL’ headache is worst in the morning is that pressure inside the head rises when you lie flat, so by morning time pressure reaches its peak and symptoms appear.

The Maths of Brain Tumour Headaches

Each year about 140 out of every million will suffer a Brain Tumour.

Of these about 2% will only have headache and nothing else – no focal neurology.

That means the chance of a new onset headache being due to a Brain Tumour is roughly 3 per million. 

Tension-Type Headache will affect about 40% of the population each year.  The chance of a new onset headache being Tension-Type Headache is about 400,000 per million. 

A new onset headache is over 100,000 times more likely to be Tension-Type Headache than a Brain Tumour Headache.  The risk is even smaller if you have a normal neurological and eye examination.

4. A New Onset Headache which is Postural – ‘Orthostatic Headache’

This is a new onset headache – usually affecting both sides of the head like an intense pressure or squeezing.  What makes this headache notable is that when you lie down flat the pain goes away completely.  

Within no more than a minute your head feels clear.  When you go to sit up or stand up again within a minute it’s back again – a tight, intense squeezing pain on both sides of the head. You lie down again the headache is better. 

This pattern of new onset headache, which changes with posture is also called an ‘Orthostatic Headache’.  It is the classic headache of low pressure inside the head.  

Other symptoms that usually come at the same time are disturbances of hearing – tinnitus or distorted hearing, and very often there is neck pain or pain between the shoulder blades.

Classic Orthostatic Headache is rare, but if present has a high (>30%) chance of being due to a low pressure problem.  The danger with low pressure headache is that it is completely incapacitating, yet can be treated effectively with an ‘epidural patch procedure’.

Diagnosis of low pressure can be very difficult and requires a contrast enhanced MRI scan of the head.  Changes are usually present on a plain non-contrast MRI but are easily overlooked.  A CT Brain Scan is usually normal, unless the low pressure is so severe that it has caused a build up of fluid in the side of the head called sub-dural collections.

5. New Onset Exercise Induced Headaches

A Headache that is only ever brought on by exercise or straining should be investigated, as this type of headache has a 20% chance of an underlying cause. 

Exercise headache is provoked by physical activity, which could be anything from running, rowing, cycling, lifting weights or climbing stairs. 

Sexual activity can also provoke this pattern of headache – usually at the height of sexual excitement there is a sudden severe headache – similar to Thunderclap Headache.

An Exercise Induced Headache feels like an intense throbbing or pressure pain building up within seconds or minutes of starting exercise.   

The pain is usually on both sides of the head, or feels like the whole head is about to explode, and can last from 5 minutes to a couple of days.

In some people the pain evolves into a pain very similar to a migraine – throbbing quality of pain with intolerance of light, noise, smell or movement – in which case the term exercise induced migraine is used.

A first ever Thunderclap Headache which is brought on by exercise needs to be managed in the same way as a spontaneous Thunderclap Headache – immediate medical attention in an Emergency Room is required.

Causes of Exercise Induced Headaches

Most people with Exercise-Induced Headaches have several bouts of the headache before seeking medical advice.  These headaches still need investigated.  After several episodes the risk of a very serious cause such as brain haemorrhage is very small.  After a first episode, especially if it was Thunderclap Headache, the risk of a dangerous cause is greater than in someone who has had several episodes.

In older people Exercise Induced Headache can also be a symptom of angina – that is heart disease and is called cardiac cephalalgia.  Older people with Exercise Induced Headaches should also be tested for heart disease (coronary artery disease).  In this case it’s heart disease not brain disease making this a dangerous headache.

The 2 most common causes of Exercise Induced Headaches are a developmental abnormality called Chiari Malformation and Low Intracranial Pressure (Spontaneous Intracranial Hypotension).   The risk of finding one of these causes of an exercise-induced headache is about 20%.

An Exercise Induced Headache needs investigated as it can be a symptom of either very high or very low pressure inside the head.

A first ever episode of sudden headache during sexual activity will need immediate investigation to rule out more serious causes – similar to the approach with Thunderclap Headache.  Repeated sudden headaches brought on by sexual activity do not often have a serious cause identified but are probably due to brain blood vessel spasm called Reversible Cerebral Vasoconstriction Syndrome.

If a cause is not found then the condition is labelled ‘Primary Exertional Headache’. 

6. New Onset Cough Induced Headaches

This rare pattern of headache goes like this:  you are completely pain free until you cough.  At the point of coughing there is a sudden and usually severe impulse of pain or pressure in the head – like being hit with a blunt object. 

You feel stunned briefly, and the pressure or pain settles down after about a minute.  Nearly every time they cough – they get the same experience. 

The pain usually feels like it affects the whole head, but it can be just the back of the head or feel like it is the front of the head.  The location is not specific.

A cough-induced headache has all the same causes and need for investigation as a Exercise-Induced Headache – mentioned above.

The classic cause of a cough induced headache, exclusively induced by coughing, is Chiari Malformation.  Low Pressure inside the head – called Spontaneous Intracranial Hypotension – can also cause a cough induced headache, although postural headache is present as well.

People with Chiari Malformation will also describe headaches provoked by laughter or changes in position eg stooping forward to pick something off the floor.

Cough Induced headaches need investigated – an MRI is required to be certain about the presence or absence of Chiari Malformation.

One Sided Cough Induced Headaches and Coughing During a Migraine

There are people with cough induced headaches that are one sided.  In my experience these patients will often have evidence of stiffness of joints in the upper part of the neck.  Cough induced pain is likely to be referred from the upper cervical spine.  The mechanical stimulus of coughing refers pain up the back, side and front of one side of the head.

During a Migraine Attack pain in the head will worsen if you cough or move.  This is a worsening of pain and is different from Cough Induced Headache where there is no pain…until you cough.  This is an important difference as people can end up undergoing unnecessary investigations or hospital admissions if a Migraine is misdiagnosed as a Cough Induced Headache.

7. New Onset Headaches with Pulsatile Tinnitus

Pulsatile tinnitus describes a whooshing noise in the head which is in time to your pulse – so if you feel your pulse the noise in your head is going at exactly the same rate.

Incidentally, pulsatile tinnitus, without headache, also requires investigation in case there is a problem with blood vessels close to the inner ear.

When pulsatile tinnitus is present with a new onset and persisting headache the most common cause is a condition of high pressure inside the head called Idiopathic Intracranial Hypertension.

The typical Intracranial  Hypertension Sufferer is a female of 20-30 years of age who is overweight (BMI of 30 or more).

The headache is usually an intense pulsating feeling at the front (both sides) or an all over headache.  To the sufferer this will usually feel like a dangerous headache and different to any previously encountered headache. 

The pain can be made worse by straining, exercise or stooping forward or coughing, and when the pain worsens the pulsatile tinnitus is often louder.  The headache can waken the sufferer.  Some people describe a pain restricted to the back of the head, and one in 3 people vomit with the headache. It is rare for this headache to be one-sided.

Sometimes the pressure in the head will evolve into a typical Migraine Headache with nausea, photophobia and intolerance of noise.

Visual Complications of High Pressure Headaches

High pressure over many weeks can damage the optic nerves – which carry light from your eye to the brain.  A Visual Field Test is needed to see if optic nerve damage has occurred.  It is the risk of visual loss that makes this one of the dangerous headaches.

Over 70% of people with Intracranial Hypertension will report brief episodes of near-complete visual loss on straining called a visual obscuration – which should alert the doctor to a possible high pressure problem.

The best clue that high pressure is present comes from examining the back of the eye and seeing swelling at the point where the optic nerve joins the back of the eye.  Swelling of the the junction between the optic nerve and the back of the eye is called papilloedema.  An optician can confirm this. 

The best treatment for Intracranial Hypertension is weight reduction, but often medication is used and procedures to reduce pressure like Lumbar Puncture, or CSF Shunts are needed if vision is threatened.

8. Headaches in someone with previous cancer diagnosis

People with a previous diagnosis of cancer need to have any new headache taken seriously, especially if the cancer diagnosis was relatively recent – within the previous 5 years.  Any one with active cancer and a new headache will tests to rule out dangerous headaches.

The reason for this is that active cancer or cancer that has been dormant can spread to the brain tissue itself – called cerebral metastases, or to the lining of the brain – called Malignant Carcinomatous Meningitis. 

Some types of cancer can also spread to the bones of the skull – bony metastases – the most likely cancers to be myeloma, breast, lung, prostate, kidney and melanoma.  These can be very painful, yet very difficult to detect even when using scanning techniques like CT and MRI.

Not just headaches – there are focal symptoms as well

In cerebral metastases the headache is almost always accompanied by epileptic seizures, significant confusion or a severe neurological deficit like paralysis or blindness.

In Malignant Carcinomatous Meningitis there is often new deafness, new facial weakness or double vision but an initial brain scan looks normal.  This is because the cancer is not present in large lumps but has coated the nerves on the surface of the brain – a Lumbar Puncture is needed to try and identify cancer cells.

Metastases to the skull bones can also be very difficult to diagnose  as they can be difficult to detect when they appear just behind the eye (at the ‘orbital apex’), or in the sphenoid and temporal bone (at the ‘clivus’ or at the ‘petrous apex’).

Cancer related headache can feel like Tension-Type Headache.  The difference is that a cancer related headache will be accompanied by a focal neurological symptom or sign, or will be getting progressively worse day by day or week by week.  Tension-Type Headache does not have these features.

Most people with a previous cancer diagnosis who develop a new onset headache will not have a dangerous headache due to cancer spreading to the head.  Most have a safe diagnosis of Tension-Type Headache or pain referred from the neck called Cervicogenic Headache.  

9. New Onset Headaches in someone with known HIV Infection

HIV infection increases the risk of a low grade infection within the head which could present with a persistent new onset headache.  Fever may or may not be present.  HIV increases the risk of serious infection called cryptococcus Meningitis.  A Brain Scan and Lumbar Puncture will confirm or rule out cryptococcus infection. 

People with HIV Infection have an increased risk of Chronic Daily Headache without finding an underlying cause.

Someone with HIV may have a dangerous headache and requires careful investigation before making a diagnosis of Tension-Type Headache, Migraine or Cervicogenic Headache.

10. New Onset Headaches with loss of menstrual cycle / loss of libido

A new onset of headache accompanied with changes in menstrual function or sexual desire can indicate a problem with the pituitary gland. The pituitary gland is the main hormone control centre in the brain.  Too much Growth Hormone, Prolactin or ACTH lead to headaches and changes in bodily function. 

Growth Hormone changes facial appearance, makes gaps appear between teeth and increases the size and shape of hands and feet (Acromegaly).

Too much Prolactin makes breast milk to appear (Galactorrhoea) and reduces libido or makes the menstrual cycle irregular.

Lastly, too much ACTH causes high blood pressure that is very difficult to control.

The headache that accompanies pituitary tumours is a dull, persistent pain which can affect any part of the head. 

The clue is not the quality of the pain, but the fact that it is new, persistent and accompanied by these changes in bodily function.  These changes in bodily function can be very subtle – it is only on looking at old photographs that many people realise that they may be getting acromegaly for example.

Some people with pituitary gland headaches describe recurrent brief intense headaches that sound like Cluster Headache.  These feel like dangerous headaches as they are so severe.

11. New Onset Headache with Scalp Tenderness and Weight Loss

This pattern of symptoms usually occurs in someone over the age of 50 years.  The headache increases over several days to a week.  Alongside the headache you lose appetite, weight or feel run down. 

The scalp is sore and tender on one side of the head.   Scalp arteries are difficult to feel – they no longer pulse and are tender to touch.

This combination of symptoms suggests Temporal Arteritis – also called Giant Cell Arteritis. 

Arteritis is one of the dangerous headaches.   It can cause permanent loss of vision in one or both eyes if left untreated.  Early treatment with steroids reduces the risk of visual loss.

In Temporal Arteritis, the ESR Blood Test is high – greater than 50mm in an hour. A positive Temporal Artery Biopsy confirms the diagnosis.

There is no one feature of Temporal Arteritis headache that accurately distinguishes it from less dangerous headaches.  The key feature is that it is a new onset pain in someone over the age of 50 years.

12. New Onset of Headache In Wintertime or after Electricity Black Out

This scenario is trying to make people remember that Carbon Monoxide Poisoning is a cause of new onset severe headaches. 

Carbon Monoxide usually comes from poorly ventilated open fires, poorly ventilated central heating systems or from use of a diesel electricity generator. 

This is why these dangerous headaches occur in cold weather or following a power cut.  Warehouse workers who operate combustion-engine machinery can also be at risk.  80% of people with Carbon Monoxide Poisoning have a  dull, generalised headache at the time of diagnosis.

This headache is exactly the same as Tension-Type Headache, although it may throb too.  The clue to the diagnosis is the situation, not the symptom itself.  The person has a completely new headache and is coming from a setting of Carbon Monoxide exposure. 

Carbon Monoxide Poisoning might affect more than one family member or work colleague.  If there is more than one person ill, do not make the mistake of thinking it’s an infection. 

Removing the person from the source of the Carbon Monoxide Gas makes the headache stop.  The headache returns when they are back to the Carbon Monoxide environment.

Carbon Monoxide Poisoning needs hospital assessment and treatment.  The diagnosis is confirmed by a blood gas analysis.

Always think of this important environmental hazard as Carbon Monoxide Poisoning can kill.

13. A new diagnosis of Cluster Headache

Cluster Headache affects one-side of the head.  It becomes very severe within a few minutes.  Most often it is in or above one eye.  During the attack the eye waters, your nose may either run or feel congested.  The pain feels like severe pressure or a hot poker in the eye.  It is almost impossible to describe the sensation – it feels so extreme.

On the affected side the eyelid may drop down and the white of the eye looks bloodshot.  The pain is so severe that it feels like you belong to another world – your mind cannot think of anything else.  It’s a dark and dangerous place.

The pain is so intense that you may feel driven to do the following: bang your head off a wall or think about trying to gouge out your eye.  Sometimes you feel driven to do a repetitive destructive behaviour.  Examples are banging fists on a table or chopping wood vigorously. 

A Cluster Headache attack lasts about an hour.

This headache may return later that day or often appears during sleep.  A person with Cluster Headache will then have similar bouts of headache every day for 4-6 weeks before they go away again.

Cluster Headache is seasonal in some people e.g. appears every autumn.  Diagnosis can be delayed as by the time you see your doctor you look completely well.  75% of people with Cluster Headache have recurrent attacks.

An enlarged Pituitary Gland or a tear in the lining of the Carotid Artery – called Internal Carotid Artery Dissection can cause the same symptoms as Cluster Headache.  This is why it is prudent to do an MRI Scan of Head in new onset Cluster Headache.

14. A New Diagnosis of Trigeminal Neuralgia

The Trigeminal Nerve is the main nerve that brings sensation from one side of the head and face.  Sudden, short-lived pains is ‘Neuralgia’. 

Trigeminal Neuralgia affects the lower half of face. You trigger Trigeminal Neuralgia by touching the face, chewing, talking, shaving, putting on make up or exposure to a breeze.

Most older people (older than 45 years) with Trigeminal Neuralgia do not have a serious cause for their symptoms. 

In younger people (younger than 45 years) Trigeminal Neuralgia can a symptom of inflammation of the brain.  Multiple Sclerosis is one of the treatable causes of brain inflammation.

If someone has Trigeminal Neuralgia affecting both sides of the face then this increases the chance that inflammation is present.  Trigeminal Neuralgia can be caused by a meningioma or nerve sheath tumour affecting the Trigeminal Nerve.

An MRI Scan is a useful investigation for Trigeminal Neuralgia that is bilateral or occurs in younger people.

15. Severe Persistent Headache with a Body Mass Index greater than 40

People, usually women, with very high Body Mass Index are prone to High Intracranial Pressure.  The headache of High Intracranial Pressure is usually a general severe headache that will not go away. 

Unidentified High Pressure causes Visual Loss.  Pulsatile tinnitus accompanies the pain of High Intracranial Pressure.  Pulsatile Tinnitus is a whooshing noise in time to your pulse.  If a Visual Field test is normal, the treatment is weight loss.  An abnormal visual field test will require treatment such as drugs (acetazolamide), lumbar punctures or even shunt surgery.

 16. Chronic Headaches that are Completely Out of Control

Chronic Daily Headache, like Chronic Migraine is one of the dangerous headaches.  Not because life is at risk, but because they stop you living a fulfilling life.

About 20% of people who attend emergency rooms for headache management are in this category.

The most common pattern of headache is a background pain or pressure that never goes away. This usually involves the whole or top of the head, or feels like a squeezing band around the head.  This daily discomfort is usually bearable.

However, every day or every few days the pain will increase and feel like Migraine.  A severe, throbbing, sickening pain and light, noise, smell and movement are intensely unpleasant.  You cannot function and have to take to bed or stop what you are doing.

You reach a point where you worry that there must be a dangerous cause for your headaches.

The diagnosis is usually Chronic Migraine if features of dangerous headaches are absent and your eye and neurological examination are normal.

Knowing this diagnosis is very important as it means that you are safe and that your pain does not mean you are in danger.  Knowing you are safe is the first step towards getting in control of Chronic Migraine.

I have written an easy to follow guide on the best options for getting control of headaches. Before you start spending lots of money on expensive headache treatments or programmes you need to sort out your thinking, make sure you’ve avoided common mistakes with medicines and have considered drug-free treatments.  

What to Do if You Suspect Dangerous Headaches?

You must see your own doctor if you suspect dangerous headaches.  An ordinary clinical examination rules out almost all of these dangerous headaches.  Your doctor will know if you need further investigation or specialist advice.

If your Headaches are Not Dangerous?

Then get started with your free online course to get you back in control.

Other useful pages for you:

Headaches on Top of the Head

Sharp Head Pains – what causes that?

Cervicogenic Headache

About Severe Headache Expert

Dangerous Headaches: References

Devenney, E., Neale, H., & Forbes, R. B. (2014). A systematic review of causes of sudden and severe headache (Thunderclap Headache). Journal of Headache & Pain, 15, 49. doi:10.1186/1129-2377-15-49

Forbes, R. B. (2014). Acute headache. Ulster Medical Journal, 83(1), 3-9.

The full list of 33 dangerous headaches references are here

Copyright 2016 of Forbes Neurology Services Ltd NI 608770 and Dr Raeburn Forbes

The post Dangerous Headaches: 16 Symptoms You Cannot Ignore appeared first on Severe Headache Expert.

8 Tips for managing migraine on a budget:

How much did you spend on your migraine last year? $50, $500, $5000, $50,000?

In the US it is estimated that migraine costs the country $17 billion each year and most of that ($12bn) is from the pockets of people with migraine. An average person with severe migraine will spend about $300 per month on their headaches and lose about $900 per month through loss of productivity at work or home.

Here’s how you can save when you manage migraine on a budget.

1. Stop buying painkillers or ‘Triptan’ drugs

Overuse of painkillers or ‘Triptan’ drugs are the number 1 reason for ongoing severe migraine.  Stopping can reduce headache by 75%.

Estimated saving: $166 per month (assumes 10 days per month of Imitrex 100mg tablets).

2. Keep Hydrated

It’s actually true that keeping a good level of hydration will improve wellbeing for people with headache – about 50% will report feeling better.  Just make sure the water is clean and safe to drink.  About 3 pints of water per day is about right for most adults.

Estimated saving: Difficult to quantify – depends what price you put on feeling better.

3. Regularly perform neck, jaw and shoulder exercises

A large trial from Italy showed that office workers who stretch their shoulders, neck and jaw muscles twice a day experienced 2 days less per month with headache and reduced painkiller use by 23%.  Check your posture and do regular stretching of neck, shoulder and jaw 2 times a day.

Estimated saving: $154-184 per month (assumes that you place a value on your time the same as an average US worker of $76 per day, your reduced painkillers costs are on top of that – say another $2 dollars per month if using Ibuprofen or $32 per month if you were using Imitrex tablets)

4. Start walking regularly

Regular exercise like walking can be as effective as medication in preventing headaches – 30 minutes twice a week is a good start.  This can reduce headaches by 30% over 2-3 months.  An easy win.

Estimated saving: $77 – $92 per month (one less headache day if you experience one headache per week plus reduced medication costs).  Also remember walking helps mood, strength, balance and your heart.

5. Learn how not to fear pain

If you can understand that recurrent headache pain is a false alarm, then you will cope with it much better.   Many people who spend a lot of money on their migraine do not know this crucial piece of information.  If you know this it will reduce your costs and help you manage migraine on a budget.

Estimated saving: Difficult to quantify – you may still have the same amount of headache but you much better prepared to cope.

6. Practise relaxation techniques

Breathing exercises that settle your pulse rate can dramatically reduce your pain levels over time.  These breathing exercises are scientifically proven and are called biofeedback techniques.  There are some great apps for smartphones that have made this technique really easy to get into. Recommended.  Biofeedback will reduce headache frequency by about 50%.

Estimated saving: $154-184 per month (NB a typical smartphone device will set you back a one off cost of about $129 e.g. Heartmath Inner Balance for iPhone)

7.  Get a Primary Care Physician (PCP or GP)- not a specialist

Yes – I’m trying to do myself out of a job, but this is true.  A primary care physician is the best starting place for managing severe headaches.  They will manage 99% of all headache problems really well and will be able to balance all your other health needs effectively.

Only see a headache specialist if your own PCP or GP refers you.  Remember that physiotherapists (who are usually much less expensive to see than doctors) can help headaches if you have upper cervical spine hypomobility.  Find out if a physiotherapist could help you.

Estimated saving: $180 per visit (Assume initial Specialist Visit $250 and PCP or Physiotherapy Visit $70, but remember PCP do less investigations than specialists, and physiotherapists do not investigate).

8. Use these common, cheaper drugs

Advertising would make you to think that branded drugs are best, but actually generic drugs offer the same benefit, often at a fraction of the cost (one twelfth in some cases).  This can be a big saver if you need to manage migraine on a budget.

The most cost-effective treatment of all for migraine is Aspirin – you must check with your doctor or pharmacist that it is safe to use in your own case (some medical conditions mean that you should not use it).

Estimated saving: None – Aspirin is a brand drug but generic acetylsalicylic acid is usually about the same price!

If Aspirin (Salicylic Acid) is safe then I use 900mg of Soluble Aspirin at the start of a bad headache.  The Soluble Aspirin works fastest when you chew it and allow it to be absorbed from the lining of your mouth.  It leaves a bitter taste that is easily washed down with some water.  Combined with an anti-sickness drug like Metoclopramide, Soluble Aspirin is as powerful as Imitrex (Imigran, Sumatriptan).

Non-branded Ibuprofen works well – again check with your pharmacist that it is safe and suitable for you, and to ask about the highest dose you can take.  Ibuprofen 600mg is recommended by most professional guidelines on migraine for treatment of an acute attack.

Estimated saving: $1 for every 6 Ibuprofen tables instead of Advil tablets (according to a reputable online retailer)

Non-branded Sumatriptan tablets are probably the best balance between cost and benefit.  To be honest I think this is as good as any of the other ‘Triptans’ in real life situations.  Combinations of Sumatriptan and Ibuprofen or combinations of Sumatriptan and Soluble Aspirin are more powerful than each one on its own.

Estimated saving: $104 per month (Imitrex 100mg is $16 per tablet and generic sumatriptan is $3 per tablet, assumes maximum of 8 tablets per month)

Beware ‘The Nocebo Effect’

If you are scared of changing your lifestyle or of changing a branded to a non-branded drug – you should know about what psychologists call ‘The Nocebo Effect‘.

The Nocebo Effect is where your belief that something won’t work is turned into reality.  If you believe that non-branded sumatriptan will not work as well as branded Imitrex (Imigran) then guess what – it probably won’t!   Proper licensed non-branded drugs should work just as well as branded drugs.

Please note do not change your medication unless you have consulted your doctor or qualified pharmacist.  This post is not an instruction for you to change medication.  It is designed to show you how a different approach could reduce your costs if you manage migraine on a budget.

Putting these 8 steps into practice should reduce the cost of managing your migraine.  They are part of my unique approach to headache called The Headache Friendly Lifestyle – an information-rich, free, online course – what your own doctor does not have time to tell you.

The post Manage Migraine on a Budget appeared first on Severe Headache Expert.

1. General Acute Headache Overview:  Forbes RB. Acute Headache. Ulster Medical Journal 2014;84:3-9 (Link to free full text)

2. Q: What constitutes a brief neurological examination? A: Forbes Quick Neurological Examination!

3. Should people with suspected meningitis have a CT prior to LP?  In short, if your patient is fully conscious, has no focal signs (see Quick Neuro Exam), and is not HIV positive then a CT Scan is not required according to the study of Hasbun et al in NEJM 2001

4. A person with Thunderclap Headache will usually describe a headache that goes from its start to maximum in about 2 seconds.  Dr Emma Devenney has published a systematic review of known causes of sudden and severe headache based upon 2345 published cases.  Note that the most common causes include ‘uncertain’ and non-specific headache.  In population based studies the most serious cause remains aneurysmal subarachnoid haemorrhage which is still reliably excluded by early CT Brain and normal CSF.

5. The Reversible Cerebral Vasoconstriction Syndrome is an emerging cause of Thunderclap Headache.  Vasoconstriction is difficult to detect.  In these cases thunderclap headache is often recurrent and can be provoked by exertion or emotion.  Focal symptoms suggest that the vasoconstriction may be causing a degree of cerebral ischaemia, but fortunately lasting serious deficits are rare.  Here is an open access systematic review of 214 published cases of reversible cerebral vasoconstriction syndrome.  Note that haemorrhage – often cortically based subarachnoid haemorrhage is a known complication of vasoconstriction.

6. How accurate is CT in detecting subarachnoid haemorrhage?  This question has recently been answered by Perry et in the BMJ in 2011 and the answer is… VERY ACCURATE.  Note that they qualify use of CT Scanning with interpretation by a qualified radiologist – interpreting CT Scans is a complex skill.

7.  The indications for an LP in acute headache include: CT negative thunderclap headache, suspected meningitis, suspected Intracranial Hypertension (CT Scan normal before LP please!).  Carcinomatous meningitis is another potential cause but this usually presents with a progressive neurological deficit due to involvement of cranial nerves and peripheral nerve roots, and not just headache.  An up to date overview of Diagnostic Lumbar Puncture has recently been published by Dr Carolynne Doherty in the UMJ.

8. If CT and LP are normal, when should I do an MRI in acute headache?  The reasons for an MRI study in acute headache are:

a) Acute arterial dissection (carotid or vertebral artery) – these usually cause a sudden, severe, unilateral headache with ptosis from Horners syndrome often present in Carotid Dissection.  Clinical features of vertebral artery dissection have been reviewed systematically;

b) Spontaneous Intracranial Hypotension – there is a postural headache – usually a dull bilateral heavy/pressure pain that is almost completely relieved by lying horizontal and accompanied by muffled hearing or other non-specific auditory symptoms.

c) Suspected Cerebral Venous Sinus Thrombosis – this is usually a new onset persistent headache often, but not always, with focal neurological deficits.  It can be missed on plain CT Brain, but the clue from a LP is an elevated opening pressure and an increased CSF protein concentration.

Patients with any of these 3 causes will usually be experiencing a persistent pain, or their history will not be typical of Thunderclap Headache.

9. New Onset Persistent Headaches.  The key diagnoses to search for and rule out are:

a) Carbon Monoxide Poisoning

b) Temporal Arteritis (ESR and age >50)

c) Cervicogenic Headache – the flexion-rotation test is a useful clinical sign that detects musculoskeletal abnormality of the upper cervical spine.  Remember that the upper 3 segments of the cervical spine will radiate pain to the head without there being obvious neck pain present.  C1 level usually radiates to the orbital area, C2 can also radiate to the back, side, top or front of the head.  C3 usually will only reach to the occiput.  This condition is under recognised.

d) Intracranial Hypotension – described above

e) Intracranial Hypertension – usually overweight younger females with persistent pressure type headaches associated with a pulsing noise in the head that is in time with their pulse.  Weight management is the best known treatment, but surgical procedures (VP shunting) may be required to prevent severe visual failure.

f) Isolated Sphenoid Sinusitis – remember isolated sphenoid sinusitis will lack classic sinus features of nasal congestion and nasal discharge – you may just get a persistent daily headache lasting for months which will often prevent sleep.

The post Acute Headache – some useful articles appeared first on Severe Headache Expert.

Results of an Internet Based Survey of Clinical Features, Investigations, Treatment, Outcome and Theories on Cause.

By Dr Raeburn B. Forbes MD(Hons) and Dr Rachael Kee MRCP

Introduction

Hypnic Headache (HH) is a rare headache disorder in which a person goes to sleep headache free and is woken at about the same time every night with a severe headache (1).

HH is recognised by the International Headache Society as a primary headache disorder in the IHC-2 (2).

Originally Hypnic Headache was regarded as a diffuse headache, but unilateral cases have been published (3). A disturbance of hypothalamic function has been proposed as a cause of Hypnic Headache (4), and even though headache and sleep are inextricably linked (5), the cause of Hypnic Headache remains obscure.

We describe results of an internet based survey to identify people with Hypnic Headache and seek their descriptions of headache symptoms, treatment options, prognosis and theories on causation. Specifically, we wanted to know what sort of research questions this population of people would wish to pursue. We compare their responses with the published literature on Hypnic Headache.

If internet based surveys are valid, then this could form a basis for creating a patient-centred research agenda. Information technology could accelerate progress in our understanding of distressing, rare, headache syndromes. There is also wider recognition that people who experience chronic illness should be engaged in generating hypotheses for future research (6).

Methods

A webpage about Hypnic Headache was written by one of the authors (RBF). After several months, it became apparent that this page was being read by several hundred people per month. One reader contacted the author and asked whether her headaches may have been caused by influenza vaccination, which led to the idea that people reading this site may be willing to suggest potential causes for their condition. A form was linked to the Hypnic Headache webpage inviting people with to answer questions about their condition, and one question specifically asked about theories on causation or antecedent events (see Appendix 1). Respondents were informed that their information would be kept confidential and that any submitted information, including email addresses would not be used for any other purpose. Data was saved on a secure server, which was password protected, and we aimed to maintain the form until approximately 100 responses were received. Data was downloaded, anonymised, and then analysed. The website is owned by a limited company which is Information Commission compliant according to UK Data Protection Laws.

We asked people with Hypnic Headache to report time from onset of symptoms to diagnosis, who made their diagnosis, how often headaches occurred, how long a headache episode lasted for, what treatments they had used and which one seemed best. When reporting outcome, people were asked to report remission (resolution of symptoms and no treatment), control of symptoms (ongoing treatment controlled symptoms and this response could either be complete or partial), or ongoing headaches in spite of treatment (refractory headache). We sought information on imaging studies and polysomnography. Lastly people were asked to submit information on their own theory on why Hypnic Headaches occurred and for suggestions for future research.

Descriptive statistics were used. Due to the nature of the data being collected we did not use statistical analysis, as this study is purely descriptive, but might allow us to generate hypotheses.

We conducted a systematic review of Hypnic Headache using the PubMed database. The search terms were: ‘hypnic’ or ‘Hypnic Headache’ OR ‘Hypnic Headaches’. We excluded articles that did not include original data on cases with Hypnic Headache, and included those that described cases, or cases series of people with Hypnic Headache. The systematic review was conducted in January 2012, and had already been initiated prior to posting the website enquiry form. Descriptive statistics were used to summarise clinical features, best treatment, secondary causes and prognosis.

Results

The Internet Survey captured 90 responses between 10th June 2012 and 3rd October 2013. Of these 80 were useable as there were 10 submissions that were either duplicate or did not contain any useful information (Table 1).

Table 1: Website visits and survey responses by month.

The systematic review identified 115 articles, of which 69 contained original data on a total of 147 cases (See Appendix 2 for full bibliography). We separated our cases into Self-reported Hypnic Headache (SRHH) and Published Hypnic Headache (PHH). Of the SRHH group there were 30 who stated that they had been diagnosed by a physician, and 45 who stated that they had self-diagnosed. 5 people with SRHH did not complete the section on who made their diagnosis.

Demographic and Clinical Features

Published cases of Hypnic Headache were older (64 years) than self-reported cases (57 years), although the self reported cases who stated that they had been diagnosed by a physician had a mean age of 62 years. Females were over-represented in the internet survey at 10 females to one male, compared to 1.5 females to 1 male in the published cases. The internet survey cases who had been diagnosed by a physician were 6 females to 1 male.

There was variability in the time to diagnosis – published cases had a shorter median time to diagnosis – 2.2 years compared to a median of 3 years for self reported cases. The median duration of an actual Hypnic Headache attack in published cases was 61 minutes, compared to a median of 105 minutes in self-reported cases. Self reported cases who stated that a physician had diagnosed their condition had a median attack duration of 90 minutes.

Self reported cases of Hypnic Headache report a mean 1.4 attacks of headache per night, with a median attack number of 1.

We tried to estimate the number of nights per month people experienced Hypnic Headaches for and found that published cases experienced Hypnic Headache on a median of 24 (Interquartile range 20 – 30) nights per month, compared a median of 17 (Interquartile range 11-25) nights for self-reported cases. Self reported cases who saw a physician experienced pain on a median of 25 nights per month (Interquartile range 17-28).

Pain Severity

In the self-reported Hypnic Headache group, 79 people completed a HIT-6 score, with an mean score of 59 (range 32 to 78) and a median score of 60 (Interquartile range 53 to 66). In 133 published cases Visual Analogue scores were often used (0-10 ratings where 0 is no pain and 10 is worst imaginable pain), and the median score was 7/10 (Interquartile range 6 to 8), and a mean score of 7 (range 2 to 10).

Previous and Family Headache History

Of the 147 published Hypnic Headache cases 38 had a history of migraine (26%) and 12 (8%) had a previous history of Tension-type headache, and 94 (64%) had no prior headache history.
In our self-reported Hypnic Headache group, 10 (12%) cases reported previous migraine headache when asked about what they thought caused their headaches. We identified 6 cases who reported Hypnic Headache in first degree relative (2 in fathers, 2 in mothers, 1 in a sister and 1 in a daughter). When asked about a family history of any headache, there were 42/80 who said that they had a first degree relative with headache, but we were not able to specify which headache disorder.

Events Prior to Onset of Hypnic Headache

When asked if there was a preceding event, 21/80 reported one or more preceding events (Table 3), including Influenza Vaccination (14 instances), Severe Respiratory Infection (5 instances), Head Injury (3 instances), Diarrhoeal Illness (3 instances), (Stroke (one instance)).

Behaviour During a Hypnic Headache Attack

When asked about behaviour during a Hypnic Headache we found a total of 197 reported behaviours from our 80 self reported cases: 43 took painkillers, 20 stayed lying in bed, 35 rubbed their head or neck, 54 reported having to get up from bed, 12 reported agitation, 23 wanted to drink coffee and 10 wanted to eat.

In the published Hypnic Headache cases, 60 cases had behaviours reported, including 51 who got up, 5 who had to walk and 2 who reported symptoms feeling worse if lying down, and 2 who wanted to sit up.

Investigations

145/147 published cases had a neuro-imaging study performed of which 129/145 were either normal or unremarkable. 6 cases reported atrophy or changes of cerebral ischaemia, and 13 cases reported an abnormality felt to be significant by the authors (Table 4). Only one malignant tumour – a cerebellar haemangioblastoma – causing Hypnic Headache has ever been published to date (7). Imaging results were submitted by 68/80 respondents, none of whom had a malignant tumour diagnosed.

Polysomnography and Sleep Phase

Polysomnography (PSG) has been reported in 17/147 published cases, of whom 11/17 were recorded as having Hypnic Headache during REM Sleep and 4/17 had onset during non-REM Sleep.
In the Self-reported cases, we identified a further 17 people with Hypnic Headache who had undergone PSG, of whom 3/17 reported onset during REM Sleep, 1/17 in non-REM sleep and 5/17 who were uncertain which phase of sleep. 7/17 self-reported cases did not get a headache during their PSG test.
Forty self-reported cases entered data on dreaming, of which 25/40 said they are dreaming at onset of Hypnic Headache, and 5/40 said that they were not, and the remaining 10 were uncertain.

Treatment

In published cases, 70 cases reported a total of 75 treatments, of which 21/70 stated that Lithium was best, followed by Indomethacin (14/70), Caffeine (5/70) and Amitryptiline (4/70). Triptans were not often quoted as successful treatments in published cases.
In self-reported cases, we had 89 different treatments reported by 78 of our 80 cases. Caffeine was the most widely reported treatment (22/80 cases) with a further 10 cases using Caffeine containing over-the-counter preparations like Excedrin. Of the 32 self-reported cases using Caffeine or Caffeine containing preparations, 10 reported remission of symptoms, 9 reported ongoing symptoms (i.e.no control), 8 reported partial control of symptoms, 2 reported that they could cope without using caffeine, and in 3 cases the effect was not stated.
Although widely recommended, Lithium was only used in 2/80 self-reported cases. Outcomes reported for other drugs included: Paracetamol (5 cases, of whom 3 reported remission), Indomethacin (4 cases, 2 remission and 2 with control of symptoms), and Triptans (7 cases, 1 remission, 3 control of symptoms, 2 ongoing and 1 unknown effect). Table 5 lists the different drugs and combinations reported as effective in managing Hypnic Headache.

14/80 self-reported cases said that nothing works, so did not report a best treatment and are likely to have refractory Hypnic Headache.

* Excedrin, Sumatriptan; Frovatriptan, Butalbital and Botulinum Toxin; Maxalt, Topiramate, Vivactal, Magnesium, Vitamin B2; Petadolor or Migraine Drop; Sumatriptan, Excedrin, Chi Gong.

** Acetazolamide, Indomethacin; Acetylsalicylic acid, Amitriptyline, Verapamil; Atenolol & Amitriptyline; Cinnarizine plus caffeine; Doxylamine, Tylenol, Eszopiclone; Indometacin and Caffeine; Indomethacin and caffeinated soda; Indomethacin, Melatonin; Lithium & Amitriptyline; Lithium and cup of coffee; Lithium and Venlafaxine; Lorazepam, Lithium;

Prognosis

Of the 147 published cases, outcomes were stated for 61 cases, of whom 56 (92%) either had remission or control of symptoms compared to 49/80 (61%) of self reported cases (Table 6). Self reported cases were therefore more likely to report refractory symptoms, and less likely to report control of symptoms than the published cases.

Theories on causation

Personal theories on causation were sought, and more than one causation theory could be proposed in a free-text box on our questionnaire. 16 people did not make any suggestions, but the most common theory was a mechanical or neck-related problem (13 suggestions – Table 7a).

Another common theme was that Hypnic Headache is a manifestation of another health problem (Table 7b).

Hormonal and dietary factors, feature in most theories of headache causation and psychological factors were also volunteered. Unsurprisingly sleep disorders are suspected, including shift work, time-zone travel and insomnia (Table 7c).

Discussion

The current world literature on Hypnic Headache is based upon less than 150 cases, and our internet survey has managed to gain information on a further 80 potential cases. We do not know if any of these self-reported cases were already published, but none of the self-reported cases made reference to being in a publication, but we cannot rule out the possibility that some of the internet based cases were already published.

Validity of Internet Survey

There are significant demographic differences between published cases and self-reported cases, the most striking of which is the over-representation of females in the self-reported cases (10:1 from survey versus 1.5:1 in published cases), and that self-reported cases tended to be younger than published cases (57 years versus 64 years). Published cases had shorter headache attack duration, shorter time to diagnosis and more frequent headache episodes per month than self-reported cases. This would make sense as self-reported cases may be tolerating milder symptoms, and may not have sought a diagnosis from a physician. In addition women are more likely to engage in health seeking behaviour than men (8), and women are more likely to search for health information on the Internet than men (9).

As there are clear differences between the population described in the published literature and the self-reported cases we are unable to confirm the validity of the diagnosis in our online sample, but if they are in any way representative they do have interesting observations on causation, treatment or potential research ideas. However, published case reports are by definition a selection of the more extreme cases. If we were to conduct a population-based epidemiologic survey of Hypnic Headache we may identify less severe cases in younger people that differ from published literature. Until a population based epidemiologic survey is completed, we will never be able to establish the true demographics of people with Hypnic Headache.

However, there are many similarities between the published cases and our self reported series e.g. the frequency of serious underlying causes was low in both groups (13/147 published cases v 4/80 internet cases), and pain severity was rated as severe in both groups, albeit using different methods. Each group had refractory cases – albeit more frequently in self-reported cases – which would reflect a bias towards not publishing cases where there was no success with treatment. These observations support an argument that our self-reported cases are likely to have true Hypnic Headache.

New findings

Our survey respondents made some observations that may be worth validating with original research. Firstly, the possibility that Hypnic Headache goes unreported to medical services, even though published literature suggests that the risk of an underlying disorder is potentially 9%. In the published cases the range of time from first symptom to diagnosis was wide, for example a case where 15 years lapsed until diagnosis (case 8 in reference (10)).

We also managed to identify a further 17 cases of Hypnic Headache who had Polysomnography – but still cannot confirm whether a majority of Hypnic Headache cases are related to REM or non-REM sleep (11)(12).

In published cases, Lithium is the most commonly reported treatment providing relief of symptoms (13), but in self-reported cases we found a strong preference for using caffeine, and a significant number felt able to cope with resorting to any medication. Caffeine is universally available and relatively safe, and in the absence of randomised trial data, our survey makes an argument for using caffeine as an initial pharmacologic intervention rather than Lithium when Hypnic Headache is diagnosed.

Prior Events to Onset of Hypnic Headache

Our data is not strong evidence that there are provoking factors prior to the onset of Hypnic Headache, as only 25% gave information on antecedent events, and influenza vaccination is commonly used in people over 60 years, and infectious illnesses are also commonplace. It is not clear why an infectious or vaccine related immune stimulus would lead to an exclusively nocturnal headache, although influenza vaccination has been linked, inconclusively, to the development of narcolepsy in children.

Theories on Causation

It is interesting to note that to date, no one has proposed that Hypnic Headache is a referred pain from the cervical spine, yet this was the most commonly reported theme. Formal examinations of the cervical spine have not been reported in any of the 147 previously published cases. Referred cervical facet joint or atlanto-axial joint pain can cause pain in the head that is diffuse (14) or unilateral (15), and these pains could mimic Hypnic Headache. Abnormal sleeping posture could, in theory, induce a nocturnal headache that arises from an upper cervical spine structure.

9/80 self-reported cases felt that their Hypnic Headache may be a manifestation of migraine, which is similar to the published literature where migraine was reported in the past medical history of 26% of cases. There are mechanisms that connect disturbed sleep and headaches (5), but the precise mechanisms connecting sleep and Hypnic Headache remain obscure.

The range of theories of causation are in keeping with what people tell doctors about what they think he causes of headache are – namely a combination of social, environmental, physical, emotional, hormonal, psychological, pathological and pharmacological factors (16).

Conclusions

Hypnic Headache is a rare headache syndrome of unknown aetiology. An internet based survey identified another 80 potential cases to add to the 147 in the published literature, although these self-reported cases were much more likely to be female and younger than published cases. Self-reported cases most commonly used caffeine, and very few reported using Lithium successfully – in contradiction to the experience of published cases.

Secondary causes of Hypnic Headache are rare, and the cause of Hypnic Headache remains obscure.

When asked about potential causes of Hypnic Headache, the most commonly proposed cause was a mechanical or neck related problem. Hypotheses generated by patients with Hypnic Headache may be worth pursuing in a formal epidemiological study.

References

1. Raskin NH. The hypnic headache syndrome. Headache. 1988;28(8):534-6.
2. The International Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004;24 Suppl 1:9-160.
3. Gould JD, Silberstein SD. Unilateral hypnic headache: a case study. Neurology. 1997;49(6):1749-51.
4. Holle D, Naegel S, Krebs S, Gaul C, Gizewski E, Diener HC, et al. Hypothalamic gray matter volume loss in hypnic headache. Ann Neurol. 2011;69(3):533-9.
5. Holland PR. Headache and sleep: Shared pathophysiological mechanisms. Cephalalgia. 2014;34(10):725-44.
6. Guise JM, O’Haire C, McPheeters M, Most C, Labrant L, Lee K, et al. A practice-based tool for engaging stakeholders in future research: a synthesis of current practices. J Clin Epidemiol. 2013;66(6):666-74.
7. Mullally WJ, Hall KE. Hypnic headache secondary to haemangioblastoma of the cerebellum. Cephalalgia. 2010;30(7):887-9.
8. Galdas PM, Cheater F, Marshall P. Men and health help-seeking behaviour: literature review. J Adv Nurs. 2005;49(6):616-23.
9. Cohen RA, PF. A. Use of the Internet for health information: United States, 2009. . Hyattsville, MD National Center for Health Statistics, 2011 2011. Report No.
10. Pinto CA, Fragoso YD, Souza Carvalho D, Gabbai AA. Hypnic headache syndrome: clinical aspects of eight patients in Brazil. Cephalalgia. 2002;22(10):824-7.
11. Manni R, Sances G, Terzaghi M, Ghiotto N, Nappi G. Hypnic headache: PSG evidence of both REM- and NREM-related attacks. Neurology. 2004;62(8):1411-3.
12. Dodick DW. Polysomnography in hypnic headache syndrome. Headache. 2000;40(9):748-52.
13. Evers S, Goadsby PJ. Hypnic headache: clinical features, pathophysiology, and treatment. Neurology. 2003;60(6):905-9.
14. Aprill C, Axinn MJ, Bogduk N. Occipital headaches stemming from the lateral atlanto-axial (C1-2) joint. Cephalalgia. 2002;22(1):15-22.
15. Cooper G, Bailey B, Bogduk N. Cervical zygapophysial joint pain maps. Pain Med. 2007;8(4):344-53.
16. Kelman L. The triggers or precipitants of the acute migraine attack. Cephalalgia. 2007;27(5):394-402.

Appendix 1: Hypnic Headache Survey Form

1 First Name
2 Country
3 Male or Female?
4 Your age today please (Years)
5 How many years did you have Hypnic Headaches before you were diagnosed?
6 When you have a Hypnic Headache how often is the pain severe?
7 How often do Hypnic Headaches limit your ability to do usual daily activities including household work, work, or social activities?
8 When you have a Hypnic Headache, how often do you wish you could lie down?
9 In the past 4 weeks, how often have you felt too tired to do work or daily activities because of your Hypnic Headaches?
10 In the past 4 weeks, how often have you felt fed up or irritated because of your Hypnic Headaches?
11 In the past 4 weeks, how often did Hypnic Headaches limit your ability to concentrate on work or daily activities?
12 When you have headaches, how often is the pain severe?
13 How often do headaches limit your ability to do usual daily activities including household work, work, school, or social activities?
14 When you have a headache, how often do you wish you could lie down?
15 In the past 4 weeks, how often have you felt too tired to do work or daily activities because of your headaches?
16 In the past 4 weeks, how often have you felt fed up or irritated because of your headaches?
17 In the past 4 weeks, how often did headaches limit your ability to concentrate on work or daily activities?
18 Have you been given a diagnosis of Hypnic Headache?
19 Who made your diagnosis?
20 Before you developed Hypnic Headache, did you have any of the following?
21 Do any of the following relatives get headaches?
22 Did any of your family members ever describe Hypnic Headaches?
23 How long does a Hypnic Headache episode last?
24 If a Hypnic Headache lasted more than 180 minutes, how long does it last for?
25 On average, how many Hypnic Headaches can you get per night?
26 Before you were treated, how many nights per month would you have had Hypnic Headaches?
27 When you waken with your Hypnic Headache, would any of the following apply?
28 Which Treatment Works Best for your Hypnic Headache?
29 If you said “other medication” please enter name here:
30 What happened when you treated Hypnic Headaches?
31 Did you have any Scans performed?
32 Was there any of the following on your brain scan?
33 Please make any other comments about any brain scans here:
34 Have you ever had Polysomnography (a detailed sleep study)?
35 If you had polysomnography, what phase of sleep did you headaches appear?
36 Are you dreaming when woken with Hypnic Headache?
37 Do you have any theories on why you get Hypnic Headaches?
38 Is there any research question you think we should try to answer?
39 Please make any other comments here:

Appendix 2:

Hypnic Headache References Identified with Systematic Review

1. Neau JP, Paquereau J, Bailbe M, Meurice JC, Ingrand P, Gil R. Relationship between sleep apnoea syndrome, snoring and headaches. Cephalalgia. 2002;22(5):333-9.
2. Evans RW, Dodick DW, Schwedt TJ. The headaches that awaken us. Headache. 2006;46(4):678-81.
3. Vieira-Dias M, Esperanca P. Hypnic Headache: report of two cases. Headache. 2001;41(7):726-7.
4. Vieira Dias M, Esperanca P. [Hypnic Headache: a report of four cases]. Rev Neurol. 2002;34(10):950-1.
5. Valentinis L, Tuniz F, Mucchiut M, Vindigni M, Skrap M, Bergonzi P, et al. Hypnic Headache secondary to a growth hormone-secreting pituitary tumour. Cephalalgia. 2009;29(1):82-4.
6. Valade D, El Amrani M. [Idiopathic facial pain other than vascular pain]. Rev Neurol (Paris). 2000;156 Suppl 4:4s57-61.
7. Ulrich K, Gunreben B, Lang E, Sittl R, Griessinger N. Pregabalin in the therapy of Hypnic Headache. Cephalalgia. 2006;26(8):1031-2.
8. Son BC, Yang SH, Hong JT, Lee SW. Occipital nerve stimulation for medically refractory Hypnic Headache. Neuromodulation : journal of the International Neuromodulation Society. 2012;15(4):381-6.
9. Sibon I, Ghorayeb I, Henry P. Successful treatment of Hypnic Headache syndrome with acetazolamide. Neurology. 2003;61(8):1157-8.
10. Seidel S, Zeitlhofer J, Wober C. First Austrian case of Hypnic Headache: serial polysomnography and blood pressure monitoring in treatment with indomethacin. Cephalalgia. 2008;28(10):1086-90.
11. Schurks M, Kastrup O, Diener HC. Triptan responsive Hypnic Headache? Eur J Neurol. 2006;13(6):666-7.
12. Scagni P, Pagliero R. Hypnic Headache in childhood: a new case report. J Paediatr Child Health. 2008;44(1-2):83-4.
13. Relja G, Zorzon M, Locatelli L, Carraro N, Antonello RM, Cazzato G. Hypnic Headache: rapid and long-lasting response to prednisone in two new cases. Cephalalgia. 2002;22(2):157-9.
14. Ravishankar K. Hypnic Headache syndrome. Cephalalgia. 1998;18(6):358-9.
15. Raskin NH. The Hypnic Headache syndrome. Headache. 1988;28(8):534-6.
16. Prakash S, Dabhi AS. Relapsing remitting Hypnic Headache responsive to indomethacin in an adolescent: a case report. J Headache Pain. 2008;9(6):393-5.
17. Porta-Etessam J, Garcia-Morales I, Di Capua D, Garcia-Cobos R. A patient with primary sexual headache associated with Hypnic Headaches. J Headache Pain. 2009;10:135.
18. Pinto CA, Fragoso YD, Souza Carvalho D, Gabbai AA. Hypnic Headache syndrome: clinical aspects of eight patients in Brazil. Cephalalgia. 2002;22(10):824-7.
19. Pinessi L, Rainero I, Cicolin A, Zibetti M, Gentile S, Mutani R. Hypnic Headache syndrome: association of the attacks with REM sleep. Cephalalgia. 2003;23(2):150-4.
20. Peters N, Lorenzl S, Fischereder J, Botzel K, Straube A. Hypnic Headache: a case presentation including polysomnography. Cephalalgia. 2006;26(1):84-6.
21. Perez-Martinez DA, Berbel-Garcia A, Puente-Munoz AI, Saiz-Diaz RA, de Toledo-Heras M, Porta-Etessam J, et al. [Hypnic Headache: a new case]. Rev Neurol. 1999;28(9):883-4.
22. Peatfield RC, Mendoza ND. Posterior fossa meningioma presenting as Hypnic Headache. Headache. 2003;43(9):1007-8.
23. Patsouros N, Laloux P, Ossemann M. Hypnic Headache: a case report with polysomnography. Acta Neurol Belg. 2004;104(1):37-40.
24. Newman LC, Lipton RB, Solomon S. The Hypnic Headache syndrome: a benign headache disorder of the elderly. Neurology. 1990;40(12):1904-5.
25. Mullally WJ, Hall KE. Hypnic Headache secondary to haemangioblastoma of the cerebellum. Cephalalgia. 2010;30(7):887-9.
26. Mulero P, Guerrero-Peral AL, Cortijo E, Jabary NS, Herrero-Velazquez S, Miranda S, et al. [Hypnic Headache: characteristics of a series of 13 new cases and proposal for modification of the diagnostic criteria]. Rev Neurol. 2012;54(3):129-36.
27. Morales-Asin F, Mauri JA, Iniguez C, Espada F, Mostacero E. The Hypnic Headache syndrome: report of three new cases. Cephalalgia. 1998;18(3):157-8.
28. Moon HS, Chung CS, Hong SB, Kim YB, Chung PW. A case of symptomatic Hypnic Headache syndrome. Cephalalgia. 2006;26(1):81-3.
29. Mitsikostas DD, Vikelis M, Viskos A. Refractory chronic headache associated with obstructive sleep apnoea syndrome. Cephalalgia. 2008;28(2):139-43.
30. Marziniak M, Voss J, Evers S. Hypnic Headache successfully treated with botulinum toxin type A. Cephalalgia. 2007;27(9):1082-4.
31. Martins IP, Gouveia RG. Hypnic Headache and travel across time zones: a case report. Cephalalgia. 2001;21(9):928-31.
32. Manni R, Sances G, Terzaghi M, Ghiotto N, Nappi G. Hypnic Headache: PSG evidence of both REM- and NREM-related attacks. Neurology. 2004;62(8):1411-3.
33. Lisotto C, Mainardi F, Maggioni F, Zanchin G. Episodic Hypnic Headache? Cephalalgia. 2004;24(8):681-5.
34. Liang JF, Fuh JL, Yu HY, Hsu CY, Wang SJ. Clinical features, polysomnography and outcome in patients with Hypnic Headache. Cephalalgia. 2008;28(3):209-15.
35. Kocasoy Orhan E, Kayrak Ertas N, Orhan KS, Ertas M. Hypnic Headache syndrome: excessive periodic limb movements in polysomnography. Agri : Agri (Algoloji) Dernegi’nin Yayin organidir = The journal of the Turkish Society of Algology. 2004;16(4):28-30.
36. Klimek A, Sklodowski P. [Night headache: report of 2 cases]. Neurol Neurochir Pol. 1999;33 Suppl 5:49-54.
37. Kerr E, Hewitt R, Gleadhill I. Benign headache in the elderly–a case report of Hypnic Headache. Ulster Med J. 2006;75(2):158-9.
38. Karlovasitou A, Avdelidi E, Andriopoulou G, Baloyannis S. Transient Hypnic Headache syndrome in a patient with bipolar disorder after the withdrawal of long-term lithium treatment: a case report. Cephalalgia. 2009;29(4):484-6.
39. Jimenez-Caballero PE, Gamez-Leyva G, Gomez M, Casado-Naranjo I. [Description of a series of cases of Hypnic Headache. Differentiation between sexes]. Rev Neurol. 2012;54(6):332-6.
40. Ivanez V, Soler R, Barreiro P. Hypnic Headache syndrome: a case with good response to indomethacin. Cephalalgia. 1998;18(4):225-6.
41. Holle D, Wessendorf TE, Zaremba S, Naegel S, Diener HC, Katsarava Z, et al. Serial polysomnography in Hypnic Headache. Cephalalgia. 2011;31(3):286-90.
42. Holle D, Naegel S, Krebs S, Katsarava Z, Diener HC, Gaul C, et al. Clinical characteristics and therapeutic options in Hypnic Headache. Cephalalgia. 2010;30(12):1435-42.
43. Holle D, Naegel S, Krebs S, Gaul C, Gizewski E, Diener HC, et al. Hypothalamic gray matter volume loss in Hypnic Headache. Ann Neurol. 2011;69(3):533-9.
44. Holle D, Gaul C, Krebs S, Naegel S, Diener HC, Kaube H, et al. Nociceptive blink reflex and pain-related evoked potentials in Hypnic Headache. Cephalalgia. 2011;31(11):1181-8.
45. Guido M, Specchio LM. Successful treatment of Hypnic Headache with topiramate: a case report. Headache. 2006;46(7):1205-6.
46. Grosberg BM, Lipton RB, Solomon S, Ballaban-Gil K. Hypnic Headache in childhood? A case report. Cephalalgia. 2005;25(1):68-70.
47. Gould JD, Silberstein SD. Unilateral Hypnic Headache: a case study. Neurology. 1997;49(6):1749-51.
48. Ghiotto N, Sances G, Di Lorenzo G, Trucco M, Loi M, Sandrini G, et al. Report of eight new cases of Hypnic Headache and mini-review of the literature. Funct Neurol. 2002;17(4):211-9.
49. Garza I, Swanson J. Successful preventive therapy in Hypnic Headache using hypnotics: a case report. Cephalalgia. 2007;27(9):1080-1.
50. Garza I, Oas KH. Symptomatic Hypnic Headache secondary to a nonfunctioning pituitary macroadenoma. Headache. 2009;49(3):470-2.
51. Fukuhara Y, Takeshima T, Ishizaki K, Burioka N, Nakashima K. [Three Japanese cases of Hypnic Headache]. Rinsho Shinkeigaku. 2006;46(2):148-53.
52. Evers S, Rahmann A, Schwaag S, Ludemann P, Husstedt IW. Hypnic Headache – the first German cases including polysomnography. Cephalalgia. 2003;23(1):20-3.
53. Evers S, Goadsby PJ. Hypnic Headache: clinical features, pathophysiology, and treatment. Neurology. 2003;60(6):905-9.
54. Donnet A, Lanteri-Minet M. A consecutive series of 22 cases of Hypnic Headache in France. Cephalalgia. 2009;29(9):928-34.
55. Domitrz I. [Hypnic Headache as a primary short-lasting night headache: a report of two cases]. Neurol Neurochir Pol. 2005;39(1):77-9.
56. Dolso P, Merlino G, Fratticci L, Canesin R, Valiante G, Coccolo D, et al. Non-REM Hypnic Headache: a circadian disorder? A clinical and polysomnographic study. Cephalalgia. 2007;27(1):83-6.
57. Dodick DW. Polysomnography in Hypnic Headache syndrome. Headache. 2000;40(9):748-52.
58. Dodick DW, Mosek AC, Campbell JK. The hypnic (“alarm clock”) headache syndrome. Cephalalgia. 1998;18(3):152-6.
59. Dodick DW, Mosek A, Campbell JK. Hypnic Headache syndrome. Reply to Dr. Ravishankar. Cephalalgia. 1998;18(10):712-3.
60. Dodick DW, Jones JM, Capobianco DJ. HH: another indomethacin-responsive headache syndrome? Headache. 2000;40(10):830-5.
61. de Godoy JM. Remission of Hypnic Headache associated with idiopathic cyclic edema with the use of aminaphtone. The open neurology journal. 2010;4:90-1.
62. Peng H, Wang L, He B, Giudice M, Zhang L, Zhao ZX. Hypnic Headache responsive to sodium ferulate in 2 new cases. Clin J Pain. 2013;29(1):89-91.
63. Cerminara C, Compagnone E, Coniglio A, Margiotta M, Curatolo P, Villa MP, et al. Hypnic Headache in children. Cephalalgia. 2011;31(16):1673-6.
64. Ouahmane Y, Mounach J, Satte A, Zerhouni A, Ouhabi H. HH: response to lamotrigine in two cases. Cephalalgia. 2012;32(8):645-8.
65. Centonze V, D’Amico D, Usai S, Causarano V, Bassi A, Bussone G. First Italian case of Hypnic Headache, with literature review and discussion of nosology. Cephalalgia. 2001;21(1):71-4.
66. Capuano A, Vollono C, Rubino M, Mei D, Cali C, De Angelis A, et al. Hypnic Headache: actigraphic and polysomnographic study of a case. Cephalalgia. 2005;25(6):466-9.
67. Caminero AB, Martin J, del Rio MS. Secondary HH or symptomatic nocturnal hypertension? Two case reports. Cephalalgia. 2010;30(9):1137-9.
68. Buzzi MG, Cologno D, Formisano R, Caltagirone C. Hypnic Headache responsive to indomethacin: second Italian case. Funct Neurol. 2005;20(2):85-7.
69. Bender SD. An unusual case of Hypnic Headache ameliorated utilizing a mandibular advancement oral appliance. Sleep & breathing = Schlaf & Atmung. 2012;16(3):599-602.
70. Baykan B, Ertas M. Hypnic Headache associated with medication overuse: case report. Agri : Agri (Algoloji) Dernegi’nin Yayin organidir = The journal of the Turkish Society of Algology. 2008;20(3):40-3.
71. Autunno M, Messina C, Blandino A, Rodolico C. Headache. 2008;48(2):292-4.
72. Arjona JA, Jimenez-Jimenez FJ, Vela-Bueno A, Tallon-Barranco A. Hypnic Headache associated with stage 3 slow wave sleep. Headache. 2000;40(9):753-4.

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