What is the treatment for Exploding Head Syndrome?

Treatment of Exploding Head Syndrome

The treatment of Exploding Head Syndrome (EHS) primarily involves reassurance about its benign nature, with tricyclic antidepressants such as amitriptyline (10-50 mg) being effective for persistent cases that cause significant distress.

Understanding Exploding Head Syndrome

Exploding Head Syndrome is a rare parasomnia characterized by:

• Perception of sudden loud noises or explosive sensations in the head
• Typically occurs during transitions between wakefulness and sleep
• Not associated with pain, despite the alarming nature of symptoms
• May be accompanied by fear, flashes of light, or distress

Diagnostic Considerations

Before initiating treatment, it's important to:

• Exclude other conditions including primary and secondary headache disorders
• Rule out nocturnal seizures
• Consider polysomnography if diagnosis is uncertain (though findings are typically unremarkable)

Treatment Algorithm

First-line Approach:

1. Reassurance and education
   • Explain the benign nature of the condition
   • Emphasize that EHS is not dangerous or indicative of serious neurological disease
   • This approach alone is sufficient for many patients 1, 2, 3

For persistent cases causing significant distress:

1. Pharmacological options:

   • Tricyclic antidepressants:
     • Amitriptyline 10-50 mg daily has shown effectiveness 3
     • Start at lower doses (10 mg) and titrate as needed

2. Address comorbid sleep disorders:

   • Treating underlying sleep problems may improve EHS symptoms 3
   • EHS is associated with poorer sleep quality, shorter sleep duration, and longer sleep onset latency 4

3. Prevention strategies reported by patients with >50% effectiveness 4:

   • Regular sleep schedule
   • Stress reduction techniques
   • Avoiding sleep deprivation
   • Relaxation before bedtime
   • Avoiding stimulants before sleep

For refractory cases:

1. Consider novel approaches:
   • Single-pulse transcranial magnetic stimulation (sTMS) has shown promise in case reports 5

Clinical Pearls and Pitfalls

• Demographics: EHS affects females slightly more than males, with median age of onset around 54 years 1
• Frequency: Attacks typically occur from once per day to once per week, though some patients experience multiple episodes per night 1
• Course: About half of patients experience a chronic course, while others have episodic or sporadic occurrences 1
• Impact: While 44.4% of individuals experience significant fear during episodes, only 25% report clinically significant distress, and only 10.1% report significant interference with daily life 4

When to Refer

Consider referral to a sleep specialist when:

• Diagnosis remains uncertain
• Symptoms are severe or causing significant distress
• First-line treatments are ineffective
• There are concerns about comorbid sleep disorders

The key to managing EHS is recognizing its benign nature while acknowledging the distress it can cause. Most patients respond well to reassurance and education, with medication reserved for those with persistent, troublesome symptoms.