Diagnosis: Exploding Head Syndrome
The diagnosis is exploding head syndrome (EHS), a benign parasomnia characterized by the perception of a loud sound or explosive sensation during sleep-wake transitions, accompanied by fear and palpitations, without associated headache, daytime sleepiness, or difficulty falling asleep. 1, 2
Clinical Features Supporting This Diagnosis
The patient's presentation is classic for EHS with the following characteristic features:
- Loud sound perception during sleep transitions - The hallmark symptom of EHS is experiencing a sudden loud noise or explosive feeling when transitioning between wake and sleep states 1, 2
- Accompanying fear and palpitations - Fear and tachycardia are among the most common accompanying symptoms in EHS, occurring in the majority of cases 2, 3
- Absence of pain - Unlike migraine with aura, EHS is not accompanied by headache 1, 4
- No difficulty falling asleep - This distinguishes EHS from insomnia, as patients with EHS do not have trouble initiating sleep 1
- No daytime sleepiness - The absence of excessive daytime sleepiness excludes other sleep disorders like narcolepsy or idiopathic hypersomnia 2
- No nightmares - This helps differentiate from nightmare disorder, which involves dysphoric dreams with recall of dream content 5
Key Distinguishing Features from Other Options
Why not insomnia? Insomnia involves difficulty falling or staying asleep with impaired daytime functioning 5. This patient has no trouble falling asleep and no daytime impairment 1.
Why not migraines with aura? Migraines with aura would involve headache and typically visual or sensory aura phenomena, not isolated loud sounds during sleep transitions 1, 2.
Why not sleep-related hallucinations? Sleep-related hallucinations (hypnagogic/hypnopompic) typically involve complex visual, auditory, or tactile experiences, often with dream-like quality, rather than the simple explosive sound characteristic of EHS 2, 3.
Clinical Course and Management
- Benign and self-limited nature - EHS is a well-defined disease entity with a benign natural history that requires no specific treatment in most cases 1, 2
- Reassurance is key - Patient education and reassurance about the benign nature of the condition is often all that is needed 1, 4
- Episodic pattern - Episodes can occur sporadically or chronically, with frequency ranging from one attack per week to several per night 2
- Treatment rarely needed - Most patients do not require pharmacologic intervention, though tricyclic antidepressants have been helpful in some cases with frequent, bothersome episodes 2
Important Clinical Pearls
The median age of onset for EHS is 54 years, with a female predominance (1.5:1 ratio) 2. Episodes are complex, with an average of 4.5 additional symptoms beyond the noise perception, and are often multisensorial 3. The condition is significantly underreported, with only 11% of patients mentioning it to healthcare professionals 3. Visual phenomena occur in approximately 27% of cases, more commonly than previously recognized 3.