What medical condition causes acute onset of headache and insomnia?

Acute Headache and Insomnia: Medical Conditions to Consider

The most critical condition causing acute onset of severe headache and insomnia is aneurysmal subarachnoid hemorrhage (aSAH), which requires immediate diagnostic workup with non-contrast head CT followed by lumbar puncture if imaging is negative. 1

Life-Threatening Causes Requiring Immediate Evaluation

Aneurysmal Subarachnoid Hemorrhage (aSAH)

For any patient presenting with acute onset severe headache, aSAH must be excluded first due to its high mortality and morbidity. 1

• The classic presentation is sudden-onset headache reaching maximal intensity immediately, often described as "thunderclap" 1
• Sentinel or warning headaches occur in 10-43% of cases before the catastrophic rupture 1
• Insomnia or sleep disturbance may accompany the acute presentation due to severe pain and neurological dysfunction 1

Diagnostic algorithm based on presentation timing: 1

• If presenting >6 hours from symptom onset OR with new neurological deficit: Perform non-contrast head CT AND lumbar puncture (LP) if CT is negative 1
• If presenting <6 hours from symptom onset WITHOUT neurological deficit: Non-contrast head CT on high-quality scanner interpreted by board-certified neuroradiologist may be sufficient to exclude aSAH 1
• If CT is negative or inconclusive: LP should be performed >6-12 hours after symptom onset with spectrophotometric analysis for xanthochromia (sensitivity 100%, specificity 95.2%) 1

Critical pitfall: Misdiagnosis or delayed diagnosis of aSAH leads to death and severe disability—maintain high clinical suspicion even with negative initial imaging 1

Primary Headache Disorders with Acute Presentations

Migraine with Sleep Disturbance

Migraine commonly presents with both acute headache and insomnia, with a bidirectional relationship between these symptoms. 2, 3

• Sleep disturbance (sleep loss, oversleeping, schedule shifts) is an acute trigger for migraine attacks 3
• Insomnia is the most prevalent sleep disorder in chronic migraine patients and increases risk for depression and anxiety 3
• The relationship is asymmetrical: headache is more strongly associated with insomnia than insomnia with headache 4

Acute migraine treatment priorities: 1

• First-line: NSAIDs (aspirin, ibuprofen, naproxen sodium) or combination acetaminophen/aspirin/caffeine 1, 5
• Second-line for NSAID failures: Triptans (oral sumatriptan, rizatriptan, zolmitriptan, or subcutaneous sumatriptan) eliminate pain in 20-30% at 2 hours but cause transient flushing/tightness in 25% 1, 5
• Alternative for cardiovascular risk patients: Gepants (rimegepant, ubrogepant) or lasmiditan (5-HT1F agonist) avoid vasoconstrictive effects 5
• For early nausea/vomiting: Use non-oral route and treat nausea aggressively with antiemetics 1

Critical pitfall: Using acute medications more than twice weekly increases risk of medication-overuse headache and should trigger preventive therapy consideration 1, 6

Cluster Headache

Cluster headache is a chronobiological disorder with strong circadian rhythmicity and preferential occurrence during REM sleep, causing both acute severe headache and sleep disruption. 2

• Shows circadian and circannual patterns with attacks often occurring at same time daily 2
• Preferentially occurs during REM sleep due to silencing of anti-nociceptive networks 2
• High association with obstructive sleep apnea 2

Acute treatment: Injectable sumatriptan and high-flow oxygen are highly effective 2

Medication-Induced Causes

Beta-Blocker Side Effects

Beta-blockers used for migraine prevention commonly cause both headache and insomnia as adverse effects. 1

• Propranolol, timolol, atenolol, metoprolol, and nadolol all report insomnia as common side effect 1
• These symptoms are "fairly well tolerated and seldom caused premature withdrawal from trials" 1
• Consider switching to amitriptyline if patient has mixed migraine and tension-type headache 1

SSRI/SNRI Antidepressants

Selective serotonin reuptake inhibitors and serotonergic/noradrenergic reuptake inhibitors may cause or exacerbate both insomnia and headache. 1

Comorbid Medical Conditions

Depression and Anxiety

Psychiatric comorbidity creates a headache-sleep-affective symptom constellation requiring comprehensive management. 1, 3, 7

• Depression and insomnia are bidirectionally related, with untreated insomnia being a risk factor for new-onset and recurrent depression 1
• Insomnia increases risk for depression and anxiety in chronic headache patients 3
• Older adults with depression and medical conditions report more sleep complaints and dissatisfaction 1

Management approach: Address all three components (headache, insomnia, psychiatric symptoms) simultaneously for optimal outcomes 7

Obstructive Sleep Apnea

Sleep-disordered breathing can present with or exacerbate headache patterns, particularly morning or awakening headaches. 2, 3, 7

• Chronic daily or morning headache patterns are "soft signs" of underlying sleep disorder 3
• Sleep apnea headache may emerge de novo or exacerbate existing migraine, cluster, or tension-type headache 3
• Treatment with CPAP/BiPAP resolves headache completely within one month 2

Screening recommendation: Consider polysomnography for patients with chronic headache patterns, even without traditional OSA risk factors (consider upper airway resistance syndrome) 7