Can medications, such as selective serotonin reuptake inhibitors (SSRIs), cause exploding head syndrome, characterized by a loud sound when falling asleep?

Exploding Head Syndrome and Medications

Exploding head syndrome (EHS) is not a known side effect of SSRIs or other medications—it is a benign primary sleep disorder characterized by sudden loud noises or explosive sensations during sleep-wake transitions. 1, 2

What Actually Causes EHS

• EHS is a primary sensory parasomnia, not medication-induced, occurring most commonly during the transition from wake to sleep or sleep to wake 1
• The median age of onset is 54 years, with a female-to-male ratio of 1.5:1 1
• The etiology remains unclear, but most sufferers believe it to be a brain-based phenomenon rather than having external causes 2
• Emotional stress is suspected as a trigger, as patients often report stressful life situations during periods of frequent attacks 3

Clinical Features to Recognize

• Frequency varies widely: from one attack per day to one per week on average, though some patients experience several attacks per night 1
• Accompanying symptoms (mean of 4.5 additional symptoms per episode) include:
  • Fear (44.4% experience significant fear) 2
  • Tachycardia 4
  • Muscle jerks/twitches 4
  • Visual phenomena (27% of cases—more common than previously recognized) 4
  • Flashes of light 1
• Episodes are most likely to occur when sleeping in a supine position 4
• Only 11% of patients report EHS to a healthcare professional 4

Why SSRIs Are Not the Cause

The provided evidence extensively documents SSRI interactions with other medications (triptans, ergotamine, MAOIs) for migraine treatment 5, perioperative management 5, anxiety disorders 5, and other conditions 5, but nowhere in the medical literature is EHS listed as a side effect of SSRIs or any other medication class.

The guidelines discuss SSRI-related adverse effects including:

• Nausea, drowsiness, dizziness 5
• Serotonin syndrome risk (with MAOIs, other serotonergics) 5
• Discontinuation syndrome 5
• Sexual dysfunction 5

EHS is conspicuously absent from these comprehensive adverse effect profiles.

Management Approach

• Reassurance is the primary intervention because of the benign nature of the syndrome 3, 6
• Most patients do not require treatment 1
• For patients with significant distress (25% report clinically significant distress, 10% report interference) 2:
  • Tricyclic antidepressants have been helpful in some patients 1
  • Clonazepam showed benefit in one case report with accompanying panic attacks 6
• Five prevention strategies with >50% reported effectiveness have been identified, though specific strategies were not detailed in the evidence 2

Critical Pitfall to Avoid

Do not attribute EHS to medication side effects and discontinue necessary psychiatric medications like SSRIs. This misattribution could lead to:

• Unnecessary medication changes
• Worsening of the underlying psychiatric condition being treated
• Continued EHS symptoms (since the medication wasn't the cause)
• Increased patient anxiety about their condition 6

If a patient on SSRIs develops EHS, the temporal relationship is coincidental, not causal. Focus on educating the patient about the benign nature of EHS and addressing any associated fear or sleep disturbance 3, 6.