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Título

Headache attributed to sleep apnea: Case report

RESUMO

Case presentation: A 61-year-old female presented to our service with chronic headache for 5 years. Initially, she had two episodes per week; however, frequency increased up to daily attacks throughout the years. Headache was bilateral, pulsating, moderate to intense, and was eventually associated with nausea. It lasted on average two hours and always occurred during the morning, usually right after awakening. There was no worsening with physical activity, nor history of photophobia, phonophobia, aura or autonomic signs. She had multiple comorbidities (i.e., type 2 diabetes, chronic renal failure, obesity, hypertension, and glaucoma), as well as nonrestorative sleep, fatigue, snoring, and nocturnal awakenings owing to pain. Neurological examination and magnetic resonance imaging were unremarkable. Amitriptyline was started and increased up to 75 mg daily. After 8 months, the patient had no improvement of the symptoms. A polysomnography (PSG) was posteriorly performed, yielding an apnea/hypopnea index of 62 events per hour. Diagnosis of obstructive sleep apnea (OSA) was made. After three months of continuous positive airway pressure (CPAP) treatment, frequency decreased to one attack per week.
Discussion: OSA is associated with chronic headache. According to the International Classification of Headache Disorders – 3rd edition (ICHD-3), sleep apnea headache is a specific entity, characterized by morning headache presenting upon awakening and lasting for less than 4 hours, in more than 15 days per month, associated with confirmed OSA by PSG and pain improvement with apnea treatment. Our patient had a pattern of tension-type headache without any response to tricyclic antidepressant. Besides, she had apnea risk factors (e.g., age, body mass index, hypertension, and post-menopausal status) and fulfilled all the criteria above-mentioned. The expressive improvement in frequency and intensity after the gold standard therapy with CPAP confirms the diagnosis.
Final comments: The relationship of sleep disturbances and headache is well known. Pain modulation and circadian rhythm share neuroanatomical structures, such as brainstem and hypothalamus. Insomnia, sleep-related breathing disorders and circadian rhythm disorders are associated with increased headache intensity, attack frequency and risk of chronification. Therefore, it should always be remembered in the evaluation of patients with risk factors and non-responsiveness to first-line treatment of primary headache.

Palavras Chave

Headache; sleep apnea syndromes; polysomnography