doi:10.1111/j.1468-2982.2007.01522.

CLINICAL CORRESPONDENCE

Exploding head syndrome: report of two new cases

A Chakravarty
Department of Neurology, Vivekananda Institute of Medical Sciences, Calcutta, India

Ambar Chakravarty, 59 Beadon Street, Calcutta 700006, India. e-mail: saschakra@yahoo.com Received 15 August 2007, accepted 11 October 2007

The exploding head syndrome (EHS) is a rare, generally nocturnal event and was rst described in 1920 by Armstrong-Jones as a snapping of the brain (1). The term EHS was coined by Pearce (2) in 1989 when he described 50 patients with this disorder. Patients generally complain of a sensation of sudden explosive noise in the head (not really a headache) usually while going off to sleep, which wakes them up from sleep. The sensation lasts for a few seconds only and disappears completely when awake, although it may recur on further attempts at sleeping. The noise had been variously described as a loud bang, shot-gun or bomb-like explosion and 10% have reported a simultaneous ash of light (2). Although there is no actual headache, the syndrome is often so terrifying that sufferers cannot be certain about the benign nature of the problem and concern may be raised that a subarachnoid haemorrhage may have occurred (3). The onset is usually over the age of 50 years, as in hypnic headache, and the condition has a slight female preponderance (2). The attacks occur with variable frequency (up to a maximum of seven in one night) for a few weeks or months. Pearce stressed the benign nature of the syndrome and suggested no specic drug therapy (2). The present report describes two new cases of EHS, one with some unusual features.

occurring nearly daily at the time of consultation. The noise occurred only once during every night, after which he could go off to sleep. His past medical history had been unremarkable and he had never suffered from any signicant headache problem. General physical and neurological examination had been unremarkable. Magnetic resonance imaging (MRI) of brain with contrast had been normal. He was prescribed Flunarazine 10 mg daily. At 6 months follow-up he had much improved and noticed the exploding head symptom only on two occasions.

Case 2
A 65-year-old man was seen in February 2007. He was hypertensive and diabetic (both well controlled on oral medication) and had been having infrequent attacks of International Headache Society migraine headache (every 24 months) without aura since the age of 15 years. For the past 4 months prior to consultation, every 23 weeks, he had been awakened while going off to sleep only during taking a daytime nap by a sudden exploding (like a bomb bursting) noise in his head lasting for only few moments. This noise was always accompanied with jerky elevation of his right arm and a queer sensation in the right side of his chest (not arm) and again lasting only momentarily. He felt quite well on waking up and could go off to sleep again. These were never accompanied by any visual ashes and never occurred during sleep at night. These sensations were very different from his migraine headaches, which lasted for several hours and the noises were not accompanied by any nausea or vomiting. Physical examination was normal and his blood presswure in the clinic was 136/80 mmHg. He had already had a MRI of brain with contrast, MR angiography of brain and two interictal sleep EEG recordings performed before consultation with the author, all of which were normal. A video EEG with
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Case 1
A 48-year-old man was seen in December 2006. For the past several months about three to four times a month, he had been having attacks of a peculiar sensation in the head likened to the noise of an exploding bomb only at night while going off to sleep. The explosion would wake him up and disappear completely the moment he woke up. There was no headache and no associated symptoms such as nausea, vomiting or any visual sensation. For the past 3 months, the frequency of these sensations had increased and had been
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A Chakravarty nifedipine (6). Although both patients in the present report responded satisfactorily to Flunarizine, it is essentially anecdotal in absence of a controlled study and because the natural history of the disorder is very variable. In polysomnographic studies (5), EHS has occurred during all sleep stages, including rapid eye movement sleep. This is consistent with the gradual increase of stage 1 sleep with advancing age, the onset of which is associated with these twilight phenomena (7). The basis for EHS is thought to be a delay in the reduction of activity in selected areas of the brainstem reticular formation as the patient passes from wakefulness to sleep (8). The pathogenesis of the motor phenomenon accompanying the EHS in case 2 remains unclear, but one could speculate on a brainstem reticular myoclonus having originated from such uninhibited neurons in the brainstem reticular formation as a part of the EHS phenomenon (exploding head noise).

daytime sleep recording was performed, but no event could be captured. He was started on Flunarazine 10 mg daily and at 4 months follow-up he did not complain of any recurrence of the exploding head sensation.

Discussion
The diagnosis of EHS is generally made on the basis of an accurate history. The event lasts only for a few moments and in essence there is no headache. Although the clinical features of case 1 generally conform to the description EHS in the literature (2), certain unusual features have been noted in case 2. Here, EHS occurred only during daytime nap and never during nocturnal sleep. Also the momentary jerky elevation of the right arm and queer rightsided chest wall sensation are unusual. None of the patients complained of seeing any ashes of light during their EHS. The accompanying motor feature noted in case 2 may raise the remote possibility of a sleep-related seizure phenomenon, but the event had been only momentary and investigations failed to reveal any focal brain abnormalitystructural or electrophysiological. Evans (4) has reported a patient having EHS with sleep paralysis as a migraine aura. Although case 2 suffered from migraine without aura, the symptoms of EHS, developing late in his life, were never followed by any headache Furthermore, the possibility of this patient having the EHS symptom and the motor phenomenon as a migraine aura without headache also seems highly unlikely in view of the extreme short duration. Taking everything together, this patients new onset symptoms seemed very distinct from his past attacks of migraine and also not an epileptic phenomenon, and would merit designation as EHS. There have as yet been no trials of therapies for EHS. However, there are anecdotal reports of benet from treatment with clomipramnine (5) and

References
1 Armstrong-Jones R. Snapping of the brain. Lancet 1920; ii:720. 2 Pearce JM. Clinical features of the exploding head syndromes. J Neurol Neurosurg Psychiatry 1989; 52:90710. 3 Green MW. The exploding head syndrome. Curr Pain Headache Rep 2001; 5:27980. 4 Evans RW. Exploding head syndrome followed by sleep paralysis: a rare migraine aura. Headache 2006; 46:6823. 5 Sachs C, Svanborg E. The exploding head syndrome: polysomnographic recordings and therapeutic suggestions. Sleep 1991; 14:2636. 6 Jaeome DE. Exploding head syndrome and idiopathic stabbing headache relieved by nifedipine. Cephalalgia 2001; 21:61718. 7 Fry JM. Sleep disorders. Med Clin North Am 1987; 71:95 110. 8 Landtblom AM, Fridriksson S, Boivie J, Hillman J, Johansson G, Johansson I. Sudden onset headache: a prospective study of features, incidence and causes. Cephalalgia 2002; 22:35460.

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