Nighttime Headaches after Age 50
In April 2016, Headache: The Journal of Head and Face Pain published the results of the largest study to date on a rare primary headache disorder called Hypnic Headache. Initial onset begins late in life, usually after age 50. It is characterized by headache pain that wakes the patient in the middle of the night, typically between 1:00 am and 5:30 am. The attack lasts for at least 15 minutes. Although the ICHD-3 criteria limit duration to not more than 4 hours, the recent study found that attacks can last up to 8 hours. Most often the pain resembles that of a tension-type headache, but migraine-like symptoms do occur in 22% of patients.
Differential Diagnosis
Nighttime headaches can occur for several reasons, so imaging studies and other medical tests are required to rule out secondary causes such as sleep apnea, hypertension, hypoglycemia, medication overuse, intracranial disorders, or even cervicogenic headaches. Other primary headache disorders can cause nighttime headaches, too.
Sleep apnea often causes headaches upon waking that resemble tension-type headaches. Untreated sleep apnea can also be a migraine trigger. A sleep study is required to confirm a suspected case of sleep apnea. Treatment with CPAP resolves this symptom.
Cervicogenic headaches are common in older patients due to cervical degenerative disc disease. Poor neck position while sleeping can create added pressure that triggers referred pain from the neck up into the head. Nerve blocks frequently resolve referred headache pain due to this problem.

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