Download - Morning Headache
REVIEWPract Neurol 2009; 9: 80–84
Not all morningheadaches aredue to braintumoursA J Larner
A J LarnerConsultant Neurologist, Walton
Centre for Neurology and
Neurosurgery, Lower Lane,
Fazakerley, Liverpool L9 7LJ, UK;
Headaches causing early morning waking, or headaches which are moreprominent on waking, always raise the suspicion of raised intracranialpressure, and hence the need for prompt evaluation to exclude the diagnosisof a brain tumour (particularly if they are associated with vomiting andpapilloedema). However, there are many other much more common causes of‘‘morning headache’’, both primary and secondary. As ever, history taking iskey to the diagnosis. Attention to the possibility of analgesic medicationoveruse is particularly pertinent, but other treatable conditions such asdepression and epilepsy must not be overlooked.
Classical clinical teaching, familiar to
practically all doctors and drummed
into all medical students, is that one
of the features of raised intracranial
pressure (ICP) is headache which causes
nocturnal or early morning waking, and/or is
worse on waking, then declining in severity
after getting up. This nocturnal or early
morning headache is thought to reflect
exacerbation of raised ICP through recum-
bency, nocturnal hypoventilation with a rise
in PaCO2 and cerebral vasodilatation,1 and
possibly increased brain metabolism during
REM (rapid eye movement) sleep.2 Such
headaches are almost invariably associated
with papilloedema, and sometimes with
vomiting which may lead to hyperventilation
and reduction of ICP. In the UK, headache
with vomiting and papilloedema is enshrined
in Department of Health guidelines for
urgent evaluation (the ‘‘two-week rule’’),
although in practice very few patients
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referred under these guidelines have such
features, or indeed cerebral tumours.3 In fact,
any patient with all three features should be
seen immediately, certainly not wait for even
two weeks, because they may very well have
raised ICP.
So, are all morning headaches due to brain
tumours with raised ICP? Clearly not, but
neurologists are often referred patients with a
history of nocturnal and/or awakening head-
aches—‘‘query raised ICP’’, in the apparent
absence of other neurological symptoms and
signs. The differential diagnosis is in fact
quite broad (see box), encompassing not only
intracranial hypertension but also a number
of primary and secondary headache disorders,
as well as general neurological, medical and
psychiatric conditions.
PRIMARY HEADACHEDISORDERSMigraineThere is a circadian variation in migraine
onset, with preferential (but not exclusive)
onset in the night or early morning, between
04:00 h and 09:00 h.4 There is an older
literature devoted to ‘‘nocturnal migraine’’
and ‘‘early morning migraine’’, although there
is no reason to believe that these forms differ
from migraine at any other time of day.
Trigeminal autonomiccephalalgiasCluster headache, the most common of the
trigeminal autonomic cephalalgias, is char-
acterised not only by its unilaterality and
associated autonomic symptoms and signs
but also by its periodicity, the attacks often
recurring at the same time of the day or
night, with perhaps 50% of patients reporting
attack onset during the night. For this reason,
it is sometimes known as ‘‘alarm clock
headache’’ (compare with hypnic headache
below). Nocturnal cluster headache attack
onset is said to be more predictable than
daytime attack onset.5
Other disorders falling within the trigem-
inal autonomic cephalalgia category may also
present with nocturnal attacks, but prepon-
derance of nocturnal rather than daytime
attacks is rare in both paroxysmal hemicrania6
and short-lasting unilateral neuralgiform
headache attacks with conjunctival injection
and tearing (SUNCT).7 In both these condi-
tions, attacks may occur throughout the
24-hour period.
Hemicrania continuaThe precise nosological position of hemicrania
continua is still debated. Although not
Differential diagnosis of nocturnal and/or awakeningheadaches
Raised intracranial pressurel Neoplasml Intracranial hypertension secondary to hydrocephalus
Primary headache disordersl Migrainel Trigeminal autonomic cephalalgias
– Cluster headache– Paroxysmal hemicrania– Short-lasting unilateral neuralgiform headache attacks with conjunctival– injection and tearing (SUNCT)
l Hemicrania continual Hypnic headachel Primary headache associated with sexual activity
Secondary headache disordersl Medication-overuse headachel Hangover headachel Giant cell (temporal) arteritisl Sphenoid sinusitisl Carbon monoxide-induced headachel Subarachnoid haemorrhage
Other disordersl Headache attributed to epileptic seizurel Sleep apnoea hypopnoea headachel Depressionl Exploding head syndrome
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currently classified with the trigeminal
autonomic cephalalgias in the International
Headache Society schema (ICHD2),8 it has
certain features in common with them,
including autonomic manifestations and
indomethacin responsiveness as seen in
paroxysmal hemicrania. Pain is, by definition,
daily and continuous, but exacerbations may
occur and these frequently awaken the
patient from sleep.
Hypnic headacheA defining characteristic of this rare primary
headache disorder is onset during sleep,
usually at a consistent time each night,
between 01:00 h and 03:00 h, hence it too
has sometimes been known as ‘‘alarm clock
headache’’ (cluster headache is another
‘‘alarm clock headache’’, see above).
Recurrent attacks of headache occur, often
in the middle or later stages of sleep, possibly
emerging during REM sleep.9 The pathogen-
esis remains unknown but may be related to
impaired inactivation of anti-nociceptive
brain structures, such as the locus coeruleus
which is normally inactivated during REM
sleep. Differentiating factors from cluster
headache include frequently bilateral headache,
the absence of autonomic features, onset in
later life, and female preponderance.10
Primary headache associatedwith sexual activityThe primary headache disorder associated
with sexual activity, previously known as
coital or orgasmic cephalalgia, may resemble
subarachnoid haemorrhage at onset,
although vomiting and loss of consciousness
are very unusual. The patients are typically
males. There are no specific data, but it would
seem likely that most episodes occur during
the evening or night hours (although the
patients are clearly not asleep). The mean age
of onset was 39 years in a series of patients
attending a dedicated headache clinic,11 and
the age range in a series presenting to general
neurology clinics was 19–56 years (mean 42
years).12 These data, admittedly from biased
samples, suggest that it is generally not
individuals in the first flush of sexual vigour
but those of a certain maturity who are most
likely to be both affected and to consult; a
group whose sexual activities may, for various
domestic and occupational reasons, be
restricted to certain times of the day, or
more precisely, night.
SECONDARY HEADACHEDISORDERSMedication-overuse headacheThe scenario of recurrent generalised head-
aches associated with escalating analgesic use,
is perhaps one of the most familiar in the
neurology clinic. Not infrequently there is a
clear history of headache waking the patient
during the night, often with the desire to
consume further analgesics. My experience
suggests that this is the most common cause of
nocturnal headache seen in general neurology
outpatient clinic practice, far exceeding either
raised intracranial pressure or cluster headache,
and on occasion being referred under the ‘‘two-
week rule’’ CNS/brain tumour guidelines.3
Hangover headacheDiagnosis of hangover headache (‘‘delayed
alcohol-induced headache’’ is the preferred
ICHD2 terminology8) should be obvious from
the history.
Giant cell (temporal) arteritisThe headache associated with giant cell
arteritis is acknowledged to be highly variable,
but when present it is often persistent and
worse at night,13 perhaps because of contact
between the pillow and tender, inflamed scalp
arteries.
Sphenoid sinusitisHeadache is the most common symptom of
acute sphenoid sinusitis (or ‘‘rhinosinusitis’’,
as in the ICHD2 classification,8 as sinusitis in
the absence of rhinitis is uncommon) often
interfering with sleep. It is rare, particularly in
isolation, and misdiagnosis common. The pain
is severe, intractable, not specifically localised,
sometimes aggravated by bending or cough-
ing, not relieved by simple analgesics, and
may be associated with facial pain. Diagnosis
may be difficult because not all patients have
pyrexia or purulent nasal discharge.14 As the
condition has potential morbidity and mor-
tality, it is very important not to miss it.
Diagnostic investigations include CT, MRI and
fibreoptic nasal endoscopy.
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Carbon monoxide-inducedheadacheClassically carbon monoxide-induced head-
ache has been described as a throbbing
diffuse headache, but systematic studies have
found this to be rare. In fact, the associated
headache is very variable in nature, with no
particular features allowing diagnosis or
exclusion.15 Carbon monoxide-induced head-
ache is seasonal, being more common in the
winter months when (faulty) gas heating
systems are in use, and cohabitants may also
have headache. People in small enclosed
spaces such as caravans and boats are
particularly likely to be affected.
Subarachnoid haemorrhageOnset of subarachnoid haemorrhage during
sleep is extremely rare, if it occurs at all. The
history here is critical, particularly whether the
patient was actually asleep, because headache
secondary to sexual activity enters the differ-
ential. Stroke apparent on awakening is more
likely to be ischaemic than haemorrhagic.16
OTHER DISORDERSEpilepsyNocturnal seizures may present with morning
headache. Although the history should clearly
indicate this diagnosis, absence of a bed
partner may mean that the diagnosis is
delayed, as exemplified by the case of a 65-
year-old single lady referred to my clinic with
a diagnosis of migraine, who gave a five-year
history of occasional (approximately monthly)
headaches present only on waking and which
gradually cleared over the course of the
morning. She also mentioned that on occa-
sion she had noticed blood on her pillow on
‘‘headache mornings’’ because she had bitten
her tongue, and on two occasions she had
wet the bed as well. The headache was an
oppressive, dopey sensation precluding atten-
dance at work, and sometimes associated
with the need for daytime sleep. A provisional
diagnosis of nocturnal (secondary general-
ised) seizures was made, but the patient
declined antiepileptic drug treatment pending
further investigation. The EEG was abnormal
with predominantly left-sided slow wave
activity, and occasional sharp wave dis-
charges over both temporal regions, suggest-
ing a potential epileptogenic focus in the left
(and possibly right) temporal region. Before
her follow-up appointment was due, the
patient was found dead in bed one morning,
perhaps as the consequence of a seizure.
Other clues to the diagnosis of nocturnal
seizures are waking up on the floor, and
dishevelled bedclothes.
Obstructive sleep apnoeahypopnoea syndromeEarly morning headache has been cited as a
feature of the obstructive sleep apnoea
hypopnoea syndrome, presumably due to
nocturnal hypercapnia secondary to alveolar
hypoventilation with resultant intracranial
vasodilatation. Although encountered on occa-
sion in the neurology clinic,17 some authorities
with extensive experience of this syndrome say
early morning headache is in fact rare.18
Moreover, the situation may be confounded,
because sleep disturbance is a migraine trigger
and, possibly, by sleep apnoea per se being a
risk factor for cluster headache.19
DepressionEarly morning waking is one of the classic
vegetative symptoms of depression, often in
association with depressive thinking.
Although headache is not a feature of
depressive disorders as enshrined in the
Diagnostic and Statistical Manual (DSM-IV)
criteria, it should not be forgotten that this
symptom is not uncommon in clinical
practice. Moreover, mood disorders can
complicate migraine and possibly chronic
tension type headache, and hence need to
be identified and treated in their own right.
PRACTICE POINTS
l Patients with headaches which wake them during the night or are presenton waking and improve after getting up, and who have associatedpapilloedema and vomiting, require immediate assessment because theymay have raised intracranial pressure.
l Many other and more common conditions may also be associated withnocturnal or early morning headaches.
l The chronobiology of many primary headache disorders has a circadianpattern with preferential headache timing during the night or earlymorning, including migraine, cluster headache and hypnic headache.
l Medication overuse headache is a common cause of nocturnal headache,with the patient waking to consume more analgesia.
l Non-headache disorders such as depression and nocturnal epilepticseizures also enter the differential diagnosis.
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Headache patients with depression (and
anxiety) have greater functional impairment
than those without.20
Exploding head syndromeThe precise nosological position of this
condition is uncertain. It may be regarded
as a physiological phenomenon in the transi-
tion from wakefulness to sleep, akin to
nocturnal myoclonus. Although said to be
quite common,21 it is seldom a presenting
symptom in the neurology clinic.
CONCLUSIONSAlthough raised ICP is the most alarming
possible cause of nocturnal and/or awakening
headaches, the sensitivity and specificity of
this symptom for the diagnosis of intracranial
hypertension has not, to my knowledge, been
systematically evaluated. ICHD2 lists only two
categories in which headache ‘‘worse in the
morning’’ is included among the diagnostic
criteria, namely ‘‘Headache attributed directly
to neoplasm’’ and ‘‘Headache attributed to
intracranial hypertension secondary to hydro-
cephalus’’.8 However, ‘‘morning headaches’’
may occur with other causes of raised ICP—
for example, the headache of idiopathic
intracranial hypertension may awaken the
patient at night.22 Nocturnal and/or awaken-
ing headache is clearly not a pathognomonic
symptom for raised ICP, far from it. Many
other headache disorders, some very common
such as migraine, as well as other neurolo-
gical and medical conditions enter the
differential diagnosis. History taking is key
to identifying them,23 and hence determining
the most appropriate pathway for investiga-
tion (if any) and management.
ACKNOWLEDGEMENTSThis article was reviewed by David Hilton-
Jones, Oxford, UK.
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