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Turtle Headache: A Case Report and Approach To Hypnic Headaches.

Dear Editor,

The first turtle headache was reported in 1972 in a patient who had bilateral headache after awakening in the early morning. The headache developed while trying to go back to sleep and feeling discomfort in the daylight. The headache went worse if he pulls his head under his bed cover (1).

In the latest beta version of international headache classification hypnic headache (HH) syndrome, 'alarm clock headache' is regarded as a rare primary headache disorder (2). The attacks mostly occur at the same time at night. The etiopathogenesis of HH is poorly understood, yet the gray matter volume changes in the posterior hypothalamus, which is the biological clock, was detected in a study including HH patients (3).

Herein we report a case of 51 year-old man, who regularly awakened from sleep at the same time of the early morning by a diffuse headache which persisted for 15 to 40 minutes since one and a half year. He noticed that the headache continued only if he returns to sleep after he wakes up but it resolves if he gets up. In the last two months he had this headache everday. He never reported any nausea, autonomic symptoms or restlessness. Cranial magnetic resonance imaging was normal. The patient was started on dual therapy including melatonin and caffeine. In the follow up visit after a month, he reported that the frequency and duration of the attacks decreased more than 50%.

Insistent circadian rhythm of these headache attacks points hypothalamic involvement and another clinical feature of HH is its therapeutic response to caffeine and melatonin (4, 5).

Distinction from other primary headaches especially from cluster headache (CH) is essential, which is an autonomic cephalgia occuring as paroxysmal excruciatingly severe unilateral pain grouped in cluster periods. The pain intensity in CH is estimated to be 100 to 1000 times worse. Another important point for HH is the exclusion of other causes of headache causing wakening from sleep including sleep apnea, nocturnal hypertension, hypoglycaemia, medication overuse and intracranial disorders. Though the diagnosis of sleep apnoea does not exclude accompanying HH syndrome (1).

Informed Consent: Verbal informed consent was obtained from patient who participated in this study.

Peer-review: Externally peer-reviewed.

Conflict of Interest: No conflict of interest was declared by the author.

Financial Disclosure: The author declared that this study has received no financial support.


(1.) Gilbert GJ. Turtle Headaches. JAMA 1982; 248: 921. [CrossRef]

(2.) Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd ed. (beta version). Cephalalgia 2013; 33: 629-808.

(3.) Holle D, Naegel S, Krebs S, Gaul C, Gizewski E, Diener HC, et al. Hypothalamic gray matter volume loss in hypnic headache. Ann Neurol 2011; 69: 533-9. [CrossRef]

(4.) Holle D, Obermann M. Hypnic headache and caffeine. Expert Rev Neurother 2012; 12: 1125-32. [CrossRef]

(5.) Peres MF. Melatonin, the pineal gland and their implications for headache disorders. Cephalalgia 2005; 25: 403-11. [CrossRef]

Pinar Gelener (1,2)

(1) Kyrenia University, Faculty of Medicine, Neurology Department, Kyrenia, Cyprus

(2) Near East University, Faculty of Medicine, Neurology Department, Nicosia, Cyprus

Corresponding Author: Pinar Gelener


Cite this article as: Gelener P. Turtle Headache: A Case Report and Approach To Hypnic Headaches. Cyprus J Med Sci 2017; 2: 46

Received: 30.06.2017

Accepted: 08.08.2017
No portion of this article can be reproduced without the express written permission from the copyright holder.
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Article Details
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Author:Gelener, Pinar
Publication:Cyprus Journal of Medical Sciences
Article Type:Letter to the editor
Date:Aug 1, 2017
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