Headache Horizons: Headaches That Roam the Night

Margaret dreaded the night. In what she was constantly reminded by her children were her Golden Years, the retired and widowed school principal had developed what she knew was an entirely dysfunctional bedtime routine. Her hand busy worrying a set of beads, she’d pace the upstairs hallway in slippers, wearing out the shag rug—trying to tire herself out—willing the over-the-counter sleep aides she consumed in alarming quantities to finally kick in. When she could scarcely set 1 foot in front of the other, Margaret would make her way into bed. An eternal optimist after all these years, she would close her eyes and pray for her family, her friends, and for a painless repose.

Yet, as always, at 1:40 am—like clockwork these last 6 months—Margaret parted company with her dreams and gripped her head in pain. A deep dull ache sprang from behind her eyes and metastasized throughout her skull. She reached over to her nightstand, gulped some pills with water, and applied an ice pack to her aching head, all of which she readied each night as part of her dysfunctional bedtime routine. As she lay in the darkness and winced in misery, Margaret thought, “Golden Years indeed”.

Next to Margaret, on most nights, lay Martin, her significant other, who she met (online, at her daughter’s prompting) a decade after her husband Will had passed. A few years younger than his girlfriend, Martin still worked part time selling insurance, a job that on occasion took him out of state. On a Tuesday, around 2:30 am on an early spring day, Martin phoned Margaret. He knew, of course, that she’d be awake, most likely clutching an icepack to her head.

“Listen, Honey,” Martin said, “I’m in the emergency room down in Huntsville. Now I’m okay, but you’re gonna’ think I’m crazy. I believe I’ve caught your headache!”

The pain that shook Martin like a rag doll from sleep, jolting him out of bed to pace his hotel room frantically 2 hours before calling Margaret, was like nothing he’d ever experienced. A shaft of blinding white-hot agony, emanating from his right eye and burrowing deep inside, crouched in some shadowy spot like a caged rabid animal. A panicky terror was spawned in subterranean brain regions Martin could not name. Although he was normally an old-school stoic type, Michael cried from the torment; curiously, only his right eye leaked.

Margaret was terrified. Through her own pain and sleeping-pill fog, she offered to drive immediately to the hospital. “No need to,” Michael replied, “They gave me something, a shot; my pain is gone. And the CAT scan was fine. I’m heading back to the hotel, maybe to get some more sleep. But the doc told me to see a neurologist right away. Maggie, I think we both need to go.”

Fortunately, Margaret and Martin were able to see the same headache specialist neurologist, an amiable woman located in the city a few miles north of their home. She elicited a comprehensive headache and medical history from each of them and did a thorough physical and neurologic examination. Because their headaches were of new onset after age 50, MRI scans were ordered and were, thankfully, unremarkable.

The neurologist diagnosed Margaret with hypnic headache. She discussed treatment options based on available scientific literature. She told Margaret that medications that alter circadian rhythm such as lithium, melatonin, and caffeine are often helpful, and that indomethacin might help if those did not. Margaret chose caffeine, in the form of 4 ounces (a half cup) of black coffee, taken just before bed. Initially doubting her neurologist’s assertion that the caffeine would not keep her up, Margaret was pleasantly surprised when the night after her first dose, she slept like a baby and woke—headache free—to the sun dappling through her curtains with the music of birds fussing outside her window.

Martin had a rougher time. Correctly diagnosed with cluster headache (CH), he began an oral steroid taper and the calcium-channel blocker verapamil, but the former quickly upset his stomach and the latter precipitously slowed his already sluggish bowels. Sumatriptan injection caused severe chest and neck pain even at the lower 3 mg dose. Zolmitriptan nasal spray was better tolerated but took over 45 minutes to become effective.

Fortunately, his neurologist had other tricks up her sleeve. On his next visit she performed an occipital nerve block and started treating Martin with the newly approved CH agent galcanezumab, at 300 mg injected subcutaneously monthly during the cluster cycle. She prescribed high-flow oxygen via a nonrebreather face mask to use at attack onset.⁶ Martin found this regimen highly effective, so he alternated high-flow oxygen with the zolmitriptan nasal spray. Soon enough, his cluster attacks were way down and he had effective tools to knock them out. He just had to be quiet when pain woke him from sleep, so that Margaret, who no longer used sleep aids and took only her black coffee each night, slept the sleep of angels at his side.

Martin’s hopes were bolstered by the neurologist telling him that he would cycle out of his headache disorder soon enough, and like Margaret, sleep soundly at night. He was looking forward to this. When the sun came up following his first headache-free night, he would celebrate. Maybe take Maggie to the movies, or to one of their beloved antique car shows. When the headaches finally broke, he knew, the world would be waiting. The golden years, all theirs, stretched out before them like an endless vista on a country road.