ARTIGO ORIGINAL
Nocturnal headache, nightmares and lithium Cefaléia noturna, pesadelos e lítio Raimundo Pereira da Silva Neto1, Célia de Paula Roesler1, Edgard Raffaelli Júnior2 1 Members of the Brazilian Headache Society 2 Honorary President of the Brazilian Headache Society and Honorary Life Member of International Headache Society Center of Neurology and Headache of Piauí, Teresina-PI, Brazil Silva Neto RP, Roesler CP, Raffaelli Jr. E Nocturnal headache, nightmares and lithium. Migrâneas cefaléias 2008;11(1):14-16
ABSTRACT Objective: To estimate the efficacy of the lithium in patients with nocturnal headache and on awakening, or nightmares, or both. Method: All the fifty three patients with headache upon awakening and nightmares (50 with nocturnal headache and three with diurnal headache) were treated with lithium. The dosage used was from 150 to 900 mg at bedtime. Results: From 53 patients, 14 (26.4%) were males and 39 (73.6%) were females, ages varying from 11 to 76 years. In these 50 patients with nocturnal headache and on awakening, 35 (70.0%) there was cessation; 10 (20.0%) frequency and intensity diminished and five (10.0%) presented no improvement after lithium administration. In 11 patients with nightmares, nine (81.8%) there was cessation; one (9.1%) frequency and intensity diminished and one (9.1%) no improvement with the treatment. Conclusion: The lithium is an efficient drug in the treatment of the nocturnal headache and on awakening and also in the nightmares. Key words: Nocturnal headache; nightmares; lithium. RESUMO Objetivo: Avaliar a eficácia do lítio em pacientes com cefaléia noturna ou ao acordar, ou pesadelos, ou ambos. Método: Foram tratados com lítio, na dosagem de 150 a 900 mg ao deitar, todos os 53 pacientes com cefaléia ao acordar e pesadelos, sendo 50 com cefaléia noturna e três com cefaléia diurna. Resultados: Dos 53 pacientes, 14 (26,4%) pertenciam ao sexo masculino e 39 (73,6%) ao sexo feminino, com idade variando de 11 a 76 anos. Dos 50 com cefaléia noturna e ao despertar, 35 (70,0%) cessaram as crises; dez (20,0%) tiveram diminuição da freqüência e intensidade e cinco (10,0%) não tiveram melhora após o tratamento com lítio. Em 11 pacientes com pesadelos, 14
nove (81,8%) cessaram as crises; um (9,1%) apresentou diminuição da freqüência e intensidade e um (9,1%) não teve melhora com o tratamento. Conclusão: O lítio é uma medicação eficaz no tratamento da cefaléia noturna e ao acordar e também no controle de pesadelos. Palavras alavras-- chave: Cefaléia noturna; pesadelos; lítio.
INTRODUCTION Nocturnal headaches, which awaken the patient from sleep during the night, occur both in cluster headache and migraine, but its study in migraine has not deserved much attention.1 Since 1988, when Raskin4 described a hypnic headache which wakened from sleep six people over 65 years of age, frequently after a dream, and which responded favorably to 300-600 mg of lithium taken before going to bed, one more use was found for lithium besides chronic cluster headache and cyclic migraine. From 1988 to 1992 we only saw two elderly people who fulfilled the requisites for the diagnosis of "hypnic headache". As our patients are always asked to fill out a headache diary we give them, in which the beginning of the attack has to be signaled with an "X" in one of four vertical columns named: Night (0-6 h), Morning (6-12 h), Afternoon (12-18 h), Evening (18-24 h), it becames apparent to us that nocturnal headache, i.e., the headache that makes people wake from sleep, was common to a large number of patients of any age. Thus, Migrâneas cefaléias, v.11, n.1, p.14-16, jan./fev./mar. 2008
NOCTURNAL HEADACHE, NIGHTMARES AND LITHIUM
the term "hypnic headache" should be reserved to cases like those described by Raskin4, and "nocturnal headache" for patients of any age.
METHOD In this study we included 53 patients. As the study progressed we became aware that patients, who complained of feeling a headache upon waking up, that is, as soon as they became conscious after sleep, should be included because they also responded favorably to lithium. Another item about which the patients started volunteering information was the disappearance of nightmares, whether they preceded a headache or not, but which had been a constant in their lives for a long time (sometimes from infancy or adolescence)3 and that had never been mitigated by any medication. All the 53 patients started being treated for migraine without aura, and only after at least three months the use of lithium was contemplated. Seven patients has been showed up again for treatment, in periods that varied from one to two years, it was evident that their headaches started during sleep or upon waking up - and all of these seven patients benefited by the prescription of lithium. The dosage used was from 150 to 900 mg at bedtime, with no complaints regarding the ingestion of up to three pills at the same time. Thirty-nine patients were females and 14 were males, ages varying from 11 to 76. Eight patients volunteered the information that presented headache and nightmares from infancy or adolescence, and three patients presented only diurnal headaches but frequent nightmares. The only child included, a boy 11 years old, had had only attacks of nocturnal migraine (never during the day) since the age of four, always after a nightmare, which ceased with 150 mg of lithium.
RESULTS As many patients had alternation of nocturnal headache with headache upon awakening, these two alternatives are considered as one in the results. Out of 53 patients, three were included because of their nightmares, as their headaches were only diurnal. It is important to observe that in 13 patients there was a clear shift of the timing of the headache, which became diurnal after the treatment.2 Side effects were observed in five patients, generally mild and short-lived: insomnia, somnolence, nausea, dizziness, and leg pains. Tremor was complained of by Migrâneas cefaléias, v.11, n.1, p.14-16, jan./fev./mar. 2008
seven patients. The only side-effects that were important occurred in five patients: 1. A 76 year old female (even though warned) took a diuretic together with lithium, and after 10 days developed mental confusion which cleared when lithium was withdrawn. 2. A 45 year old female, who had hypothyroidism in the past, became symptomatic again. She continued taking lithium together with drugs for the thyroid condition. 3. Two men, one 46 and the other 51, developed a nefrogenic insipid diabetes which made lithium to be withdrawn, even though their headaches had improved. 4. Only one patient, a 65 year old male, refused to go on taking lithium, because the benefit he obtained from the drug was not sufficient to compensate for the muscular weakness he felt when he took it. Table 1. Patients with headache nocturnal and on awakening Evolution
Patients
%
Cessation Frequency and intensity diminished No improvement
35 10 5
70.0 20.0 10.0
Total
50
100.0
Table 2. Patients with nightmares Evolution Cessation Frequency and intensity diminished No improvement Total
Patients
%
9 1 1
81.8 9.1 9.1
11
100.0
DISCUSSION If a patient does not have a headache diary it is practically impossible to keep track of the moment when the headache starts. Besides, the shift from nocturnal to diurnal headache can only be detected by using the diary. The same applies to the frequency and duration of the pain, because between one visit and the other to the cephaliatrist the patient has only a vague recollection of the intervening pains in that period. Another important use of the diary is to make sure that the pain starts during sleep, and that it is not a sequel of a pain which the patient had before going to bed.
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RAIMUNDO PEREIRA DA SILVA NETO E COLABORADORES
REFERENCES 1. Arjona JA, Jiménez-Jiménez FJ, Vela Bueno A, Tallón-Barranco A. Hypnic headache associated with stage 3 slow wave sleep. Headache. 2000;40(9):753-4. 2. Pérez-Martínez DA, Berbel-García A, Puente-Muñoz AI, SáizDíaz RA, de Toledo-Heras M, Porta-Etessam J et al. Cefalea hípnica: un nuevo caso. Rev Neurol. 1999;28(9):883-4. 3. Dodick DW, Mosek AC, Campbell JK. The hypnic ("alarm clock") headache syndrome. Cephalalgia. 1998;18(3):152-6. 4. Dodick DW, Jones JM, Capobianco DJ. Hypnic headache: another indomethacin-responsive headache syndrome? Headache. 2000;40(10):830-5. 5. Vieira Dias M, Esperança P. Hypnic headache: report of two cases. Headache. 2001;41(7):726-7. 6. 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. 7. Dunner DL, Stallone F, Fieve RR. Prophylaxis with lithium carbonate: an update. Arch Gen Psychiatry. 1982;39(11):1344-5. 8. Peatfield RC. lithium in migraine and cluster headache: a review. J R Soc Med. 1981;74(6):432-6.. 9. 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. 10. Raskin NH. The hypnic headache syndrome. Headache. 1988;28(8):534-6. 11. Dexter JD, Riley TL. Studies in nocturnal migraine. Headache. 1975;15(1):51-62. 12. Raffaelli E, Menon AD. Migraine and the limbic system. Headache. 1975;15(1):69-78.
Endereço para correspondência Dr aimundo PPereira ereira da Silva Neto Dr.. R Raimundo Centro de Neurologia e Cefaléia do Piauí Rua São Pedro, 2071/Centro Ed. Raimundo Martins – Salas 303/304 64001-260 – Teresina-PI – Brasil Tel./fax: + 55 86 3221.9000
[email protected]
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