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A Case of Sick Sinus Syndrome Presenting as Exploding Head Syndrome Hye Yun Kim, Do Young Yoon, Dong Sun Kim, Ji Sun Kwon and Hyun Jeong Han Department of Neurology, Myongji Hospital, Kwandong University College of Medicine, Goyang, Korea Received December 3, 2012 Revised December 24, 2012 Accepted December 24, 2012 Address for correspondence Hyun Jeong Han, MD, PhD Department of Neurology, Myongji Hospital, Kwandong University College of Medicine, 697-24 Hawjeong-dong, Deogyang-gu, Goyang 412-270, Korea Tel: +82-31-810-5403 Fax: +82-31-969-0500 E-mail: [email protected] Exploding head syndrome (EHS) is a rare syndrome experienced with explosive noise happening in a head. A 78 year old man visited for intractable headache with explosive noises. His vieo-electroencephalography monitoring showed tachy-brady arrhythmia on electrocardiogram. We diagnosed as a sick sinus syndrome (SSS) presented with EHS. We suggest SSS should be considered with the elderly patients who have EHS symptom. J Korean Sleep Res Soc 2012;9:61-63 Key Words: Sick sinus syndrome, Headache. Copyright © 2012 Korean Sleep Research Society 61 CASE REPORT J Korean Sleep Res Soc 2012;9:61-63 ISSN 1738-608X Exploding head syndrome (EHS), which is a rare primary headache syndrome is characterized with explosive noise hap- pening in a head. 1 EHS was first described as the syndrome of ‘snapping of the brain,’ by Armstron-Jones in 1920. In 1988, Pearce reported 50 patients with EHS. The cluster attacks, happening at night time over weeks, followed by prolonged remissions. 1 Patients with EHS described variously as ‘loud bang’, ‘short gun’ or ‘bomb-like explosions’. 2 EHS is more af- fected commonly in women than men and older than 50 years old. Case Report A 78 year old man visited our neurology clinic for intrac- table headache, which persisted for 2 months. He had no per- tinent medical history such as hypertension, cardiac disease or diabetes mellitus. He described his symptoms as sudden attacks with big noise in his head like a bomb explosion and persisting headache for half or one hour. e location of pain was mainly vertex area with moderate to severe intensity. e patient said that the character of pain cannot be explained by a simple word and oſten experienced almost loss of conscious- ness with the pain. e pain attack was not controlled by pain medication and occurred two or three times a day, mainly in the evening or at night. The attacks were aggravated at night before bed time. His blood pressure was 130/75 mm Hg and there was not sig- nificant finding on results of routine serologic and cardiologic studies including electrocardiogram (ECG). Also on the re- sult of brain magnetic resonance imaging, there were no sig- nificant lesions and no abnormality of arterial nor venous stu- dies on the angiography. To rule out seizure episode, video- electroencephalogram (EEG) monitoring with ECG was per- formed from the evening to the next morning. During the video EEG monitoring, there was no significant finding, how- ever, it was shown a tachy-brady arrhythmia accompanying with the headache attack on the ECG (Fig. 1). In detail, the pa- tient was awake but calmly lying down during having tachy- brady arrhythmia and sinus pause on the ECG. In the middle of pause was presenting, the patient took action to sit up and was complaining having noise attack from just before. We can mark the point of the attack started and assume the point was at several seconds aſter sinus pause. Though detail cardiologic evaluations, he was diagnosed with sick sinus syndrome (SSS) and the pain attack gradually dis- appeared with insertion of pacemaker. Discussion Sick sinus syndrome is a condition, which involves sinus online © ML Comm

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Page 1: A Case of Sick Sinus Syndrome Presenting as Exploding … · A Case of Sick Sinus Syndrome Presenting as Exploding Head Syndrome node dysfunction, and commonly affects elderly patients.3

A Case of Sick Sinus Syndrome Presenting as Exploding Head Syndrome

Hye Yun Kim, Do Young Yoon, Dong Sun Kim, Ji Sun Kwon and Hyun Jeong HanDepartment of Neurology, Myongji Hospital, Kwandong University College of Medicine, Goyang, Korea

Received December3,2012Revised December24,2012Accepted December24,2012

Address for correspondenceHyunJeongHan,MD,PhDDepartmentofNeurology,MyongjiHospital,KwandongUniversityCollegeofMedicine,697-24Hawjeong-dong,Deogyang-gu,Goyang412-270,KoreaTel:+82-31-810-5403Fax:+82-31-969-0500E-mail:[email protected]

Explodingheadsyndrome(EHS)isararesyndromeexperiencedwithexplosivenoisehappeninginahead.A78yearoldmanvisitedforintractableheadachewithexplosivenoises.Hisvieo-electroencephalographymonitoringshowedtachy-bradyarrhythmiaonelectrocardiogram.Wediagnosedasasicksinussyndrome(SSS)presentedwithEHS.WesuggestSSSshouldbeconsideredwiththeelderlypatientswhohaveEHSsymptom. J Korean Sleep Res Soc 2012;9:61-63

Key Words: Sicksinussyndrome,Headache.

Copyright © 2012 Korean Sleep Research Society 61

CASE REPORTJ Korean Sleep Res Soc 2012;9:61-63 ISSN 1738-608X

Explodingheadsyndrome(EHS),whichisarareprimaryheadachesyndromeischaracterizedwithexplosivenoisehap-peninginahead.1EHSwasfirstdescribedasthesyndromeof‘snappingofthebrain,’byArmstron-Jonesin1920.In1988,Pearcereported50patientswithEHS.Theclusterattacks,happeningatnighttimeoverweeks,followedbyprolongedremissions.1PatientswithEHSdescribedvariouslyas‘loudbang’,‘shortgun’or‘bomb-likeexplosions’.2EHSismoreaf-fectedcommonlyinwomenthanmenandolderthan50yearsold.

Case Report

A78yearoldmanvisitedourneurologyclinicforintrac-tableheadache,whichpersistedfor2months.Hehadnoper-tinentmedicalhistorysuchashypertension,cardiacdiseaseordiabetesmellitus.Hedescribedhissymptomsassuddenattackswithbignoiseinhisheadlikeabombexplosionandpersistingheadacheforhalforonehour.Thelocationofpainwasmainlyvertexareawithmoderatetosevereintensity.Thepatientsaidthatthecharacterofpaincannotbeexplainedbyasimplewordandoftenexperiencedalmostlossofconscious-nesswiththepain.Thepainattackwasnotcontrolledbypainmedicationandoccurredtwoorthreetimesaday,mainlyintheeveningoratnight.Theattackswereaggravatedat

nightbeforebedtime.Hisbloodpressurewas130/75mmHgandtherewasnotsig-

nificantfindingonresultsofroutineserologicandcardiologicstudiesincludingelectrocardiogram(ECG).Alsoonthere-sultofbrainmagneticresonanceimaging,therewerenosig-nificantlesionsandnoabnormalityofarterialnorvenousstu-diesontheangiography.Toruleoutseizureepisode,video-electroencephalogram(EEG)monitoringwithECGwasper-formedfromtheeveningtothenextmorning.DuringthevideoEEGmonitoring,therewasnosignificantfinding,how-ever,itwasshownatachy-bradyarrhythmiaaccompanyingwiththeheadacheattackontheECG(Fig.1).Indetail,thepa-tientwasawakebutcalmlylyingdownduringhavingtachy-bradyarrhythmiaandsinuspauseontheECG.Inthemiddleofpausewaspresenting,thepatienttookactiontositupandwascomplaininghavingnoiseattackfromjustbefore.Wecanmarkthepointoftheattackstartedandassumethepointwasatseveralsecondsaftersinuspause.

Thoughdetailcardiologicevaluations,hewasdiagnosedwithsicksinussyndrome(SSS)andthepainattackgraduallydis-appearedwithinsertionofpacemaker.

Discussion

Sicksinussyndromeisacondition,whichinvolvessinus

online © ML Comm

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A Case of Sick Sinus Syndrome Presenting as Exploding Head Syndrome

nodedysfunction,andcommonlyaffectselderlypatients.3SSShasmultiplemanifestationsonECG,suchassinusbradycar-dia,sinusarrest,sinoatrialblock,andalternativebradycardiaandtachycardia,calledbradycardia-tachycardiasyndrome,whichwaspresentinthepatient.4

PatientswithSSSareoftenasymptomaticornonspecific.Symptomsarethoughttobetheresultfromdecreasedcardiacoutput,duringarrhythmicattacks.5Therefore,mostpatientswithSSSsometimesshowedpresyncopeorsyncope,asare-sultofcerebralhypoperfusion.Othersymptomsincludewa-kefulnessduringnight,memoryloss,errorsinjudgement,lethargyandlightheadedness.3,6Inthecase,thereisnosigni-ficantfindingonscreeningECGandnoothersignificantsymptomwhichcanbepresentedacardiologicdisease.Thepatientonlyexplainedtheexperienceofexplosivenoseinhisheadandpersistentheadache.ThesymptomcorrespondedwithEHSandhewasdiagnosedasaEHSruledoutofothercardiologicissues.

ThediagnosisofSSSmightbedifficultbecausethesymp-tomsarevarietyorasymptomatic.Therefore,manypatientswithSSSareoftenruledoutofotherdiseases,likeashappen-inginthiscase.SomeelderlypatientswithSSSoftenmisdiag-nosedasaseniledementiapresentingwithgraduallossofme-mory.6

Througha24hourHoltermonitoringdetectingcardiacar-rhythmiaisneededforaproperdiagnosisofSSS.TherearemanyothermethodstodiagnosisSSSsuchasisometrichandgripexercise,carotidmassageorValsalva’smaneuversunder-goingECGmonitoring.5Inthiscase,thepatientwasper-

formeda24hoursHoltermonitoringtodiagnoseofSSS.Thepatientwasinsertedpacemakeranddidnotexperiencethesymptomthathecomplainedofbefore.

Explodingheadsyndromeisnotwellknowntophysicians.Thecausativeetiologyisalsonotunderstoodwell.7Thepos-siblemechanismshavebeensuggestedtheresultofasuddenmovementofamiddleearcomponentoftheeustachiantubeandminorseizureintemporallobe.7Tocorrectdiagnosis,weshouldruleouttheotherdiagnosiswhichcanhavesimi-larsymptomssuchasthunderclapheadache,hypnichead-ache,nocturnalparoxysmalhemicrania,lowvolumesub-arachnoidhemorrhageandnocturnalepilepsy.8Therefore,thepatientswithEHSneedtoperformbrainimagesorEEG.Theloudnoises,whichEHSpatientscanhave,mightalsobeacommonsymptominSSS.OnanothersimilarityistherangeoffrequentaffectedagebetweenEHSandSSS.Withthat,wesuggestaddingSSSasanotherdifferentialdiagnosisofEHSespeciallyinelderlypatientswithorwithoutriskfactorsofcardiacproblems.

REFERENCES

1.PearceJM.Explodingheadsyndrome.Lancet1988;2:270-271.2.CasucciG,d’OnofrioF,TorelliP.Rareprimaryheadaches:clinicalin-

sights.Neurol Sci2004;25Suppl3:S77-S83.3.BrignoleM.Sicksinussyndrome.Clin Geriatr Med2002;18:211-227.4.ColquhounM.Whenshouldyoususpectsicksinussyndrome?Practi-

tioner1999;243:422-425.5.DurhamD,WorthleyLI.Cardiacarrhythmias:diagnosisandmanage-

ment.Thebradycardias.Crit Care Resusc2002;4:54-60.6.Wozakowska-KapłonB,OpolskiG,KosiorD,Jaskulska-NiedzielaE,

Maroszynska-DmochE,WłosowiczM.Cognitivedisordersinelderly

Fig. 1. Video EEG monitoring. ECG during video EEG monitoring showed tachy-brady arrhythmia (arrow). EEG: electroencephalogram, ECG: electrocardiogram.

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www.sleepnet.or.kr 63

Kim HY et al.

patientswithpermanentatrialfibrillation.Kardiol Pol2009;67:487-493.

7.GreenMW.Theexplodingheadsyndrome.Curr Pain Headache Rep

2001;5:279-280.8.SachsC,SvanborgE.Theexplodingheadsyndrome:polysomnographic

recordingsandtherapeuticsuggestions.Sleep1991;14:263-266.


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