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Expert Column

Recurring Nighttime Headaches

Q: I am a 63-year-old woman with some type of headache that generally occurs during the night. I wake up because of severe pain above my right eye. Sometimes it travels down the right side of my head. I have to get up, and then I typically take two Excedrin® Migraine. If I stay up for 20 minutes, take a shower or eat something, it eases up and is almost gone.

Recently, however, I had the most severe attack yet. I followed my regular pattern, but this headache stayed for about five hours. I also experienced numbness on the right side of my head when the headache was at its worst. My family physician did a CT scan and other tests, which came out clear. I wonder, could this be a tension-type headache?

A: The normal test results are reassuring. I assume you had a blood test called a “sedimentation rate” to rule out temporal arteritis. If not, this should be done, because temporal arteritis occurs in persons over age 50 and can lead to loss of vision if not diagnosed and treated promptly. The headache of temporal arteritis, however, is usually more constant and persistent, not episodic as your headache appears to be.

It would be quite unusual for a tension-type headache to awaken a person, but it can happen, especially if bruxism—grinding or clenching of the teeth—is involved. Bruxism can occur at night and may be due to stress and/or a disorder of the temporal mandibular (jaw) joint (TMJ). A dentist can usually tell you if you have a bite problem or if you show signs of excessive clenching. If your headache occurs only sporadically, a TMJ disorder or clenching could be a factor.

The most common headache that wakes people up is cluster headache. Cluster attacks cause very severe pain, occur almost nightly for several weeks and then cease. The attacks are usually, but not always, accompanied by redness and tearing of the involved eye along with nasal congestion on the same side. The attacks last 30 to 120 minutes.

Another form of nocturnal headache is hypnic headache, and this is what I suspect you have. This is not a very common condition, and very little is known about it. It typically wakes a person up in the early morning hours. The pain is not as intense as in cluster headache and does not have the associated eye redness and tearing. It may be one-sided as in your case, but often is located more in the middle of the forehead. Once it begins, it tends to occur most nights, but not as frequently or on as regular a schedule as cluster. It usually stops spontaneously after several weeks or months.

Taking caffeine at bedtime is reported to be helpful in preventing hypnic headache attacks for some people. Excedrin, which you are taking, contains a moderately high amount of caffeine. Other medications reported to be helpful include certain antidepressants, nonsteroidal anti-inflammatory drugs and lithium carbonate taken before sleep as a preventive medication.

Robert Kunkel, MD, consultant, Center for Headache and Pain Neurological Institute, Cleveland Clinic, Cleveland



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