Over the past few years I have suffered occasional bouts of tinnitus and have to say that when it occurs it completely dominates all my thoughts and thinking (although I’ve been told by more than one person that my excessive i-Pod use is to blame and therefore somewhat self-inflicted medical condition). A condition that must be a hundred times worse is that of ‘Exploding Head Syndrome’ (EHS). The condition was first reported by the Welsh psychiatrist Dr. Robert Armstrong-Jones almost 100 years ago in The Lancet
(and described as “a snapping of the brain”
). A much more recent detailed description of 50 EHS cases was reported by British neurologist Dr. John Pearce in a 1989 issue of the Journal of Neurology Neurosurgery and Psychiatry
(following an initial short report of 10 cases that Pearce published in a 1988 issue of The Lancet
EHS is known to be a type of hypnagogic auditory hallucination where the person experiences a very sudden and brief loud (but usually painless) noise originating from inside their head for a fraction of a second. Some EHS sufferers also report that the loud noise may sometimes be accompanied by breathing irregularities and/or intense light flashes (so called ‘visual sleep starts’). Those who have experienced such loud noises have likened it not only to an explosion, but to a wide range of very loud noises. The 1989 paper by Dr. Pearce listed 50 patient descriptions that included gunshot, loud electrical buzzing, a loud Xmas cracker, thunderclap, a clash of cymbals, loud ringing, crashing waves, loud screaming and roaring, loud electrical static, and/or slamming car doors. There doesn’t appear to be any typical pattern among sufferers, although most EHS sufferers claim the number of attacks diminish over time following initial frequent occurrences. Some individuals experience it just once without any reoccurrence.
Any hypnagogic condition means by definition that it occurs around the onset of sleep (or the early stages of getting to sleep) and EHS is no different. (Hypnagogia refers to the state of being between awake and asleep, often called the ‘twilight of sleep’). Although the loud noise may be part of dreaming, many sufferers report that dreaming is not a necessary condition to induce the inner noise. Following an EHS attack (often experienced in the left side of the head), some individuals may experience fear and anxiety and/or heart palpitations. It is thought to be slightly less prevalent among men than women, and is more prevalent as people get older (i.e., there is much higher incidence in individuals aged over 50 years although there are reports among pre-pubescents).
Although there is no formal treatment for EHS, various therapies have been tried. Case reports have shown that some medicines appear to reduce EHS symptoms including clonezapam (reported in the journal Neurology ), clomipramnine (reported in the journals Sleep  and Cephalalgia ), and nifedipine (reported in the journal Cephalalgia ). Two cases were successfully treated using flunarizine (in the journal Cephalalgia ). Other medications have been tried but EHS sufferers have not shown any improvement including doxepin, citalopram, trimipramine, and amitriptyline, valproic acid, amitriptyline, propranolol oxycodone, and gabapentin. The most recently published case study involving treatment of EHS that I am aware of was a short 2010 paper by Dr. Gaurang Palikh and Dr, Bradley Vaughn and published in the Journal of Clinical Sleep Medicine. They described the case of a women with EHS who was successfully treated using pharmacotherapy (in this case, topiramate medication). The authors reported that:
“A 39-year-old female reported symptoms of a loud bang and buzzing noise at sleep onset for 3 years. She said that, if the sound was external, her ‘husband should be able to hear it downstairs when she was up in her bedroom. Associated with this noise, she experienced brief jerking movement of her head, leg, or arms at sleep onset on a daily basis. She noted these symptoms for years; because of the increase in intensity and frequency, she saw a neurologist. The patient had become anxious about these events, fearing that they were a hallmark of more serious medical issues. Her neurological exam, laboratory test results, and neuroimaging were normal. Because of the stereotypic nature of the events and the level of disturbance to the patient, she was admitted for continuous video EEG monitoring for 4 days. Coincidently, the patient’s neurologist prescribed topiramate 50 mg twice a day for migraine prophylaxis…Two months after admission, she reported improvement in the intensity of the noise. At a daily dose of topiramate 200 mg, the patient reported the bang had significantly improved, and now sounded like a low buzzing noise. The frequency of the events was unchanged, but the intensity of the events decreased to the point of being mildly noticeable. She had marked improvement in subjective ability to fall asleep and felt these events were no longer disruptive”.
It is not known why EHS occurs although there is some speculation that it is associated with the withdrawal from prescription drugs, extreme fatigue, and/or stress. There are also some reports that EHS attacks sometimes occur when individuals have out-of-body experiences. As a consequence, some EHS sufferers develop insomnia because of a fear about going to sleep or resting. Others experience a loss in appetite. The mechanism by which the loud noise is heard is also unknown although there are speculative reasons such as being due to minor seizures in the brain’s temporal lobe (the location of hearing’s nerve cells) or sudden movements in the middle ear. Some research has monitored EEG brain activity during actual EHS attacks that show atypical brain activity among some (but certainly not all) EHS sufferers. Although the condition appears to be very rare, it certainly exists and most people appear to get better over time (with or without treatment).
References and further reading
Armstrong-Jones, R. (1920). Snapping of the brain. The Lancet, 196, 720.
Chakravarty, A. (2008). Exploding head syndrome: Report of two new cases. Cephalalgia, 28, 399-400.
Gordon, A.G. (1988). Exploding head (letter), The Lancet, 198, 625-626.
Jacome, D.E. (2001). Exploding head syndrome and idiopathic stabbing headache relieved by nifedipine. Cephalalgia, 21, 617-618
Palikh, G.M. & Vaughn, B.V. (2010). Topiramate responsive exploding head syndrome. Journal of Clinical Sleep Medicine, 6, 382-383.
Pearce, J.M. (1988). Exploding Head Syndrome. The Lancet, 332, 270-271.
Pearce, J.M. (1989), Clinical features of the exploding head syndrome. Journal of Neurology Neurosurgery and Psychiatry, 52, 907–910.
Sachs, C. & Svanborg, E. (1991), The exploding head syndrome: polysomnographic recordings and therapeutic suggestions. Sleep, 14, 263-266.
Salih, F., Kleingebiel, R., Zschenderlein, R., & Grosse P. (2008). Acoustic sleep starts with sleep onset insomnia related to a brainstem lesion. Neurology, 70, 1935-1936.
Jacome, D.E. (2001). Exploding head syndrome and idiopathic stabbing headache relieved by nifedipine. Cephalalgia, 21, 617-618.