ISSN 0017-8748 doi: 10.1111/head.12321 Published by Wiley Periodicals, Inc.

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Clinical Correspondence Does Suicide Cause Suicide Headache? Giorgio Zanchin, MD; Matteo Bellamio, MD; Ferdinando Maggioni, MD Keywords: episodic cluster headache, trigger factor, suicide (Headache 2014;54:745-746)

self-injurious behaviors during attacks while attempting any effort to stop the pain, even going so far as to worsen the situation and make it more dangerous to themselves. Indeed, they may beat their heads, strike objects with their fists, or even bang their heads against a wall. Available data on CH triggering and aggravating factors are limited; the possible role of grief for the suicide of a beloved person as a potential trigger of a CH attack has never been reported. In this correspondence, we report a 58-year-old woman who had a complete and uneventful medical history, and who followed a healthy lifestyle; specifically, she did not smoke nor drink alcohol. She came to our observation on June 20, 2012. Since the end of April 2012, she had suffered attacks of “an excruciating pain, impossible to resist,” localized in the frontoorbital and nasal regions on the right side, which lasted 2 hours and recurred every day around 11:00 a.m. Attacks were accompanied by omolateral ptosis and restlessness.This cluster, which had begun 3 days after she learned that the young son of a close friend had committed suicide, ended only a few days before she came to our practice for observation. A neurological examination was normal. Cerebral MRI without gadolinium showed signs of chronic sinusitis in the maxillary, ethmoid, and sphenoid sinuses. In May, an otolaryngology (ORL) specialist had ruled out any causal relationship with headache and treated sinusitis with methylprednisolone 16 mg and antibiotics orally

Since antiquity, evidence suggests that headache is considered one of the most excruciating types of pain, and can lead sufferers to attempt suicide, as reported in book XXV, chapter VII of Natural History by Pliny the Elder (23-79 A.D.)1 Cluster headache (CH) is a primary trigeminal–autonomic headache classified as episodic (ECH) or chronic (CCH). Horton termed it “suicide headache” because the excruciating pain by which it is characterized can lead CH sufferers to consider suicide. An extreme example has been cited: that of a CH patient who, suffering from chronic CH, during an unbearable attack fired a shotgun at his head. The available data are quite variable. Suicidal ideation is reported to occur amongst 55% of the CH population, although only 2% admit actual suicide attempts. Jurgens et al reported suicidal tendencies in 22% of CCH patients, in 15% of ECH patients during the bout, and in 14% in the interval between bouts,2 whereas the percentages reported by Robbins et al were 5.9% of CCH patients and 6.3% of ECH without distinguishing between during or outside the bout.3 In addition, about half of CH sufferers would adopt potentially From the Headache Centre, Department of Neurosciences, University of Padua, Padua, Italy (G. Zanchin, M. Bellamio, and F. Maggioni). Address all correspondence to F. Maggioni, Via Giustiniani 5, 35128 Padua, Italy. Accepted for publication November 28, 2013.

Conflict of Interest: None.

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746 for 10 days, during which the patient was asymptomatic; headache reappeared the day after treatment was discontinued. The patient had suffered a similar episode in December 2011. This cluster, which lasted just a week, had started 4 days after the news of the suicide of a close friend. According to International Classification of Headache Disorders criteria, our patient appeared to suffer from ECH. After a 16-month follow-up, our patient did not present with further clusters nor experiences any major emotional events. Data available on CH patients are too scarce to permit making a list of triggers, such as has been evidenced in migraine (M) and tension-type headaches (TTH). Indeed, M and TTH patients are able to recognize several specific factors that could act as triggers: the most commonly reported include emotional stress, menses, weather changes, and disrupted sleep patterns. Hard drinking and/or smoking have been identified as high-risk behaviors that could be related to CH attacks; however, it is significant that these conditions act as triggers only during the bouts while they are ineffective in the period between clusters. More than half of CH patients are hard drinkers (65%) and recognize alcohol consumption as a trigger in the cluster period (53.8%). The vast majority of the CH population (73%) also present with a significant history of smoking.Furthermore,a recent head trauma has been reported as a possible cause of CH although a definite relationship is difficult to prove. Conditions which lower blood oxygenation can trigger or complicate CH attacks: an association has been reported

April 2014 between obstructive sleeping apnea and CH attacks.4 Other triggers are nitroderivatives, histamine, or vasodilators that can directly activate the trigeminal– vascular system. Our patient, however, never smoked nor drank wine or spirits, nor was she exposed to any of the above-mentioned triggers.We did not find any data on the potential role of emotional factors, more specifically linked to the suicide of a beloved person, in triggering CH attacks. In our case, both clusters were strictly related temporally to a grief of significant intensity. The apparent causal relationship between the emotional impact of such tragic events and CH (also called “suicide headache”) episodes warrants further investigation of the inverse possibility, ie, that an extraordinarily stressful experience such as the suicide of a beloved person, causing a shattered psychological status, could act as a CH trigger.

REFERENCES 1. Maggioni F, Maggioni G, Mainardi F, Zanchin G. Headache and suicide. A historical note. Headache. 2013;53:388-389. 2. Jürgens TP, Gaul C, Lindwurm A, et al. Impairment in episodic and chronic cluster headache. Cephalalgia. 2011;31:671-682. 3. Robbins MS, Bronheim R, Lipton RB, et al. Depression and anxiety in episodic and chronic cluster headache: A pilot study. Headache. 2012;52:600-611. 4. Mitsikostas DD, Viskos A, Papadopoulos D. Sleep and headache: The clinical relationship. Headache. 2010;50:1233-1245.

Does suicide cause suicide headache?

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