A Case of Sick Sinus Syndrome Presenting as Exploding Head Syndrome

Hye Yun Kim, Do Young Yoon, Dong Sun Kim, Ji Sun Kwon and Hyun Jeong HanDepartment of Neurology, Myongji Hospital, Kwandong University College of Medicine, Goyang, Korea

Received December3,2012Revised December24,2012Accepted December24,2012

Address for correspondenceHyunJeongHan,MD,PhDDepartmentofNeurology,MyongjiHospital,KwandongUniversityCollegeofMedicine,697-24Hawjeong-dong,Deogyang-gu,Goyang412-270,KoreaTel:+82-31-810-5403Fax:+82-31-969-0500E-mail:neurohan@kd.ac.kr

Explodingheadsyndrome(EHS)isararesyndromeexperiencedwithexplosivenoisehappeninginahead.A78yearoldmanvisitedforintractableheadachewithexplosivenoises.Hisvieo-electroencephalographymonitoringshowedtachy-bradyarrhythmiaonelectrocardiogram.Wediagnosedasasicksinussyndrome(SSS)presentedwithEHS.WesuggestSSSshouldbeconsideredwiththeelderlypatientswhohaveEHSsymptom. J Korean Sleep Res Soc 2012;9:61-63

Key Words: Sicksinussyndrome,Headache.

Copyright © 2012 Korean Sleep Research Society 61

CASE REPORTJ Korean Sleep Res Soc 2012;9:61-63 ISSN 1738-608X

Explodingheadsyndrome(EHS),whichisarareprimaryheadachesyndromeischaracterizedwithexplosivenoisehap-peninginahead.1EHSwasfirstdescribedasthesyndromeof‘snappingofthebrain,’byArmstron-Jonesin1920.In1988,Pearcereported50patientswithEHS.Theclusterattacks,happeningatnighttimeoverweeks,followedbyprolongedremissions.1PatientswithEHSdescribedvariouslyas‘loudbang’,‘shortgun’or‘bomb-likeexplosions’.2EHSismoreaf-fectedcommonlyinwomenthanmenandolderthan50yearsold.

Case Report

A78yearoldmanvisitedourneurologyclinicforintrac-tableheadache,whichpersistedfor2months.Hehadnoper-tinentmedicalhistorysuchashypertension,cardiacdiseaseordiabetesmellitus.Hedescribedhissymptomsassuddenattackswithbignoiseinhisheadlikeabombexplosionandpersistingheadacheforhalforonehour.Thelocationofpainwasmainlyvertexareawithmoderatetosevereintensity.Thepatientsaidthatthecharacterofpaincannotbeexplainedbyasimplewordandoftenexperiencedalmostlossofconscious-nesswiththepain.Thepainattackwasnotcontrolledbypainmedicationandoccurredtwoorthreetimesaday,mainlyintheeveningoratnight.Theattackswereaggravatedat

nightbeforebedtime.Hisbloodpressurewas130/75mmHgandtherewasnotsig-

nificantfindingonresultsofroutineserologicandcardiologicstudiesincludingelectrocardiogram(ECG).Alsoonthere-sultofbrainmagneticresonanceimaging,therewerenosig-nificantlesionsandnoabnormalityofarterialnorvenousstu-diesontheangiography.Toruleoutseizureepisode,video-electroencephalogram(EEG)monitoringwithECGwasper-formedfromtheeveningtothenextmorning.DuringthevideoEEGmonitoring,therewasnosignificantfinding,how-ever,itwasshownatachy-bradyarrhythmiaaccompanyingwiththeheadacheattackontheECG(Fig.1).Indetail,thepa-tientwasawakebutcalmlylyingdownduringhavingtachy-bradyarrhythmiaandsinuspauseontheECG.Inthemiddleofpausewaspresenting,thepatienttookactiontositupandwascomplaininghavingnoiseattackfromjustbefore.Wecanmarkthepointoftheattackstartedandassumethepointwasatseveralsecondsaftersinuspause.

Thoughdetailcardiologicevaluations,hewasdiagnosedwithsicksinussyndrome(SSS)andthepainattackgraduallydis-appearedwithinsertionofpacemaker.

Discussion

Sicksinussyndromeisacondition,whichinvolvessinus

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A Case of Sick Sinus Syndrome Presenting as Exploding Head Syndrome

nodedysfunction,andcommonlyaffectselderlypatients.3SSShasmultiplemanifestationsonECG,suchassinusbradycar-dia,sinusarrest,sinoatrialblock,andalternativebradycardiaandtachycardia,calledbradycardia-tachycardiasyndrome,whichwaspresentinthepatient.4

PatientswithSSSareoftenasymptomaticornonspecific.Symptomsarethoughttobetheresultfromdecreasedcardiacoutput,duringarrhythmicattacks.5Therefore,mostpatientswithSSSsometimesshowedpresyncopeorsyncope,asare-sultofcerebralhypoperfusion.Othersymptomsincludewa-kefulnessduringnight,memoryloss,errorsinjudgement,lethargyandlightheadedness.3,6Inthecase,thereisnosigni-ficantfindingonscreeningECGandnoothersignificantsymptomwhichcanbepresentedacardiologicdisease.Thepatientonlyexplainedtheexperienceofexplosivenoseinhisheadandpersistentheadache.ThesymptomcorrespondedwithEHSandhewasdiagnosedasaEHSruledoutofothercardiologicissues.

ThediagnosisofSSSmightbedifficultbecausethesymp-tomsarevarietyorasymptomatic.Therefore,manypatientswithSSSareoftenruledoutofotherdiseases,likeashappen-inginthiscase.SomeelderlypatientswithSSSoftenmisdiag-nosedasaseniledementiapresentingwithgraduallossofme-mory.6

Througha24hourHoltermonitoringdetectingcardiacar-rhythmiaisneededforaproperdiagnosisofSSS.TherearemanyothermethodstodiagnosisSSSsuchasisometrichandgripexercise,carotidmassageorValsalva’smaneuversunder-goingECGmonitoring.5Inthiscase,thepatientwasper-

formeda24hoursHoltermonitoringtodiagnoseofSSS.Thepatientwasinsertedpacemakeranddidnotexperiencethesymptomthathecomplainedofbefore.

Explodingheadsyndromeisnotwellknowntophysicians.Thecausativeetiologyisalsonotunderstoodwell.7Thepos-siblemechanismshavebeensuggestedtheresultofasuddenmovementofamiddleearcomponentoftheeustachiantubeandminorseizureintemporallobe.7Tocorrectdiagnosis,weshouldruleouttheotherdiagnosiswhichcanhavesimi-larsymptomssuchasthunderclapheadache,hypnichead-ache,nocturnalparoxysmalhemicrania,lowvolumesub-arachnoidhemorrhageandnocturnalepilepsy.8Therefore,thepatientswithEHSneedtoperformbrainimagesorEEG.Theloudnoises,whichEHSpatientscanhave,mightalsobeacommonsymptominSSS.OnanothersimilarityistherangeoffrequentaffectedagebetweenEHSandSSS.Withthat,wesuggestaddingSSSasanotherdifferentialdiagnosisofEHSespeciallyinelderlypatientswithorwithoutriskfactorsofcardiacproblems.

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Fig. 1. Video EEG monitoring. ECG during video EEG monitoring showed tachy-brady arrhythmia (arrow). EEG: electroencephalogram, ECG: electrocardiogram.

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