Brief Answer:
Dysautonomic cephalgias

Detailed Answer:
Good afternoon. My name is Dr. Saghafi and I am a Neurologist from the XXXXXXX OH area. Obviously, there could be other reasons for your wife's condition when I as a headache specialist hear the description of "sharp shooting pains in different locations countless number of times during the night" my first impression is that of what we refer to as PRIMARY STABBING HEADACHES. They occur mainly in women in their mid to late 40's (when they start). They can come on any time of the day or not....they can attack one part of the head or different. They can occur from 1-200x/day. There are usually no other symptoms such as nausea, vomiting, flashing lights, etc. They last 1 second or less. Very disruptive to sleep, work, and social activities.

MRI would not be expected to be abnormal in any way.

She should see a headache specialist to confirm the diagnosis and also run bloodwork and other tests as necessary, however, I think this is the diagnosis that will want to be considered mainly.

Treatment is usually INDOMETHACIN which calms at least 70-80% down with these types of headaches. The problem with indomethacin is tolerability. Most individuals develop side effects which require the drug be stopped. Check with her doctor but I would recommend a very slow titration schedule starting at 25 mg. once daily and then, little by little getting up to 3x/day and then, slowly inching up to 50 mg. 3x/day over a period of 6-8 weeks. There is also a very common side effect that needs to be reported and that is changes in stool color which could represent GI tract bleeding.

But when the medicine works....believe me it works like a charm!

I'd appreciate the favor of a HIGH STAR RATING and some written feedback if your question has been satisfactorily answered.

Also, CLOSING THE QUERY on your end will be most helpful and appreciated so that this transaction can be expeditiously processed.

Don't forget that my webpage to keep me abreast as to how your wife is doing with this or any other medical problem in the future is:

bit.ly/drdariushsaghafi

All the Best

This query has required a total of 50 minutes of physician specific time to read, research, and compile the return envoy to the patient.

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Brief Answer:
Headaches with features of dysautonomia

Detailed Answer:
Good afternoon and thank you for the additional information.

I agree that the headaches your wife experiences seem to be triggered by the supine position or lying down. This is not a typical type of presentation we see with primary stabbing headaches. in fact, relatively few types of headaches come on or are triggered by lying down. One of them, however, is altitude sickness where a person will actually develop migraine like symptoms upon lying down due to sudden engorgement of the blood vessels within the meninges of the brain that's causing a rapid rise in intracranial pressure and yielding severe headaches.

The same thing can basically happen and people who are taking medications that tend to retain salt in the body increasing the relative volume of the circulatory system and causing actual hypertension upon lying down.

Most of the headaches that we commonly see as classified by the international classification of headache diseases that are related to postural changes occur when the patient stands up from the lying position. And they improve when lying down especially in cases where there are lesions such as intraventricular colloid tumors and things of that nature which can block the outflow of cerebrospinal fluid when the patient stands up causing severe headaches but then get significantly better when the patient lies down since the tumor then has a ball like action and releases pressure on the valve so that fluid can once again flow through the ventricular system of the brain.

However, I believe in your wife's case an argument can be made that although supine pain is not described to this point as part of the classic jabs and jolts types of headaches- that she has enough characteristic features of these types of headaches so as to suggest the possibility that she may be suffering from a dysautonomic form of headache.

One could argue that upon lying down if in fact she is suffering from a form of hypersensitivity of the stretch receptors within the meninges of the brain where blood volume increases upon lying down that this dysautonomia could very well set the stage for the jabs and jolts types of headaches that come on at night. My guess is that any time she lies down she will be prone to getting these types of headaches.

Therefore, given the fact that I am answering this type of problem in a very restricted format setting and I do not have an opportunity to actually examine her and go through what would be a normal process of collecting data on a headache diary over time, measuring blood pressures in different positions, and doing what would amount to be an autonomic work up
my approach to diagnosing her headache type would be to consider it a variant of primary stabbing headaches with an additional feature of an ultra sensitive peripheral pain threshhold receptor system which is triggered by an increase in intracranial vascular volume (i.e. engorgement of the meningeal blood vessels).

Therefore, possible treatments for this type of a picture would include the typical first line medication of indomethacin which I generally start at a very low dose and gradually work up over time so as not to exceed approximately 75 to 100 mg daily until I can tell that the patient actually tolerates the regimen. unfortunately, even though indomethacin is a very effective treatment for this autonomic types of headaches it is also one of the least tolerated in terms of gastrointestinal side effects and especially G.I. bleeding which tends to change color of the stool.

However, if you seek out a good neurologist or headache specialist with experience in using indomethacin for these types of headaches they will also know what the alternatives are in case side effects do develop. this would be step one of the treatment protocol.

Step two of our approach would be to do something to reduce intravascular volume while in the supine position meaning that she should take something in order to reduce the circulating blood volume by a small percentage but we do not want to necessarily have her remain at a depleted volume 24 hours per day therefore, I would use a rather small dose of either carbamazepine, phenytoin, or Diamox, in that order due to preference.

Still another approach could be the prophylactic use of a very small dose of a vasoconstrictor such as ergot it mean which is useful for most cases of migraine types of headaches (although these are not really along the same lines as migraines) but nevertheless they may cause enough of the vasoconstriction of the meningeal blood vessels in order to counter act and balance off the increased vascular volume when she lies down.

Again, I believe the best type of specialist for this sort of procedure would be a headache specialist with a fair amount of experience in treating dysautonomia's and dysautonomic types of headaches.

there is a clear downside to using forgot a mean in her case since it would have to be done virtually on a daily basis. We would not want her to suffer from what is known as medication overuse headaches which can occur when using a board of medications for headaches greater than 15 days per month or 15 doses per month which ever comes first.

Therefore, I would reserve the use of forgot it means as a class of medication to isolated circumstances perhaps for the purpose of testing her vascular sensitivity to these medications to see if in fact they can counterbalance the intravascular volume increases that occur when she lays down.

Again, I would recommend doing an autonomic work up for your wife to discover whether or not what she's experiencing in terms of hypersensitivity of the meningeal pain receptors is also translated into other phenomenon that she may or may not be well aware of at this time. For example, she may be on the front end of developing something which is quite common in females referred to as postural orthostatic tachycardic syndrome or (POTS). In this syndrome, headaches especially of a migraine type are quite common. In other words, there is a chance that the jabs and jolts she is experiencing overtime may "morph" into migraine types of headaches. As a matter fact, you may have already read this but jabs and jolts or primary stabbing headaches are most frequently encountered on a background of migraine headaches and mostly in women of your wife's age. Since you haven't said anything about her having migraine headaches then, I believe that there is a possibility she may develop such headaches in the future if we are unable to diagnose this condition now and Bring it under control.

if these answers satisfactorily relate to your questions then, I'd appreciate the favor of a high star rating with some written feedback on your part.

Also, closing the query on your end will be most helpful and appreciated so that this question can be transacted and archived expeditiously and for further use by colleagues as necessary.

I am happy to answer an additional question in this set if you have any but if not please keep me informed as to the outcome of your wife's condition.

The query has required a total of 110 minutes of physician specific time to read, research, and compile a return envoy to the patient.

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