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CASE REPORT
Year : 2023 | Volume
: 14
| Issue : 2 | Page : 104-105
Laughter-induced headache? Yes, it is possible!
Soumya Bhowmik, Kuljeet Singh Anand
Department of Neurology, ABVIMS and Dr. RML Hospital, New Delhi, India
Correspondence Address:
Dr. Soumya Bhowmik
Department of Neurology, ABVIMS and Dr. RML Hospital, New Delhi - 110 001
India
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/injms.injms_136_22
There have been well-known headache precipitants already documented in the literature. Laughter has previously been found as a rare trigger of headache in some individuals. Laughter-induced headache is a rare type of triggered headache which can share some similarities with primary cough headache or primary exercise headache. We report a case of abrupt onset, bilateral temporo-occipital headache, typically triggered exclusively by loud laughter in a 30-year-old male, with normal neurological examination and neuroimaging brain. The patient has shown some excellent responses to treatment with sodium valproate.
Keywords: Laughter-induced headache, primary cough headache, primary exercise headache
Several specific precipitating factors of migraine headaches or other incapacitating headache disorders are already well known in the literature. A few rare unusual and underrecognized precipitants are crying, shouting, straining in stools, urination, orgasm, childbirth, and powerlifting. Laughing has also previously been reported as a trigger of headache. We report a case of headache in a 30-year-old male, precipitated exclusively on loud laughter with excellent response to sodium valproate prophylaxis.
Case ReportA 30-year-old right-handed male, without any prior comorbidity presented with a 1-year history of intermittent attacks of abrupt onset, bilateral temporo-occipital headache, typically triggered by loud laughter and lasting hardly for 2 to 5 min. The intensity of a headache is moderate-to-severe with a bursting “thunderclap” character. There is no history of fever, vomiting, loss of consciousness, or seizure. His past history is unremarkable. There is no history of any addiction or chronic drug intake. There is no family history of migraine. There is no history of any similar headaches after bending, coughing, sneezing, sexual activity, or exercise.
On examination, the general survey is unremarkable and blood pressure was recorded as 116/66 mmHg in the right arm supine posture. In an attempt, to Valsalva maneuver severe headache is noted. His complete neurological including neuro-ophthalmological examination is normal.
The routine hematological and biochemical investigations are normal including a normal erythrocyte sedimentation rate and C-reactive protein. His magnetic resonance imaging of the brain with a screening of the cervical spine is normal without any evidence of the posterior fossa space-occupying lesion or craniovertebral junction anomaly. Magnetic resonance angiography of the brain is also reported to be normal.
His headache symptom remained unresponsive to conventional headache medications prescribed over the counter. Later on, he reported to have a significant reduction in headache severity and intensity with prophylactic treatment with sodium valproate 200 mg twice a day for 3 months follow-up along with advice to avoid loud hearty laughter.
DiscussionLaughter has previously been found as a rare trigger of headaches in some individuals. In many a patient having triggered headache, either they fulfill the diagnostic criteria of migraine or they have a family history of migraine.[1] In 1956, 21 patients with headache precipitated by coughing, laughing, sneezing, straining to defecate, or stooping had been reported by Symonds.[2] Later in 1968, Rooke reported 93 patients with exertional headaches without any detectable intracranial pathology.[3] Morales-Asín, et al. reported a patient with short-lasting, sharp headaches induced by vigorous laughter, yelling, or straining at stool, found to have type I Arnold– Chiari malformation More Details.[4]
Laughter-induced headache (LH) can be primary, without any identifiable cause, or secondary due to some other underlying causes.[5] Secondary LH was found to be associated with a change in the posterior fossa cranial structure and cerebrospinal fluid dynamics such as in Arnold–Chiari malformation type-1, Giant Pacchionian granulations, intracranial tumors, posterior arachnoid cysts, intracranial hypotension, and unruptured posterior communicating artery aneurysm.
LH has not been classified separately in the International Classification of Headache Disorders-3b (ICHD-3b). Headache precipitated primarily by cough or exercise is classified under primary cough headache (PCH) or primary exercise headache (PEH). Headache, attributed to Arnold–Chiari malformation type 1 which is found to be a cause of secondary LH, has been described in the ICHD-3b.[6] The mechanism behind the short-lasting headache attacks in Arnold–Chiari malformation type-1, patients seem to be associated with the Valsalva maneuvers, a process that may induce transient pressure dissociation between intracranial and intraspinal compartments.[7]
The attack of LH is similar to PCH as it is usually sudden in onset, reaches a peak immediately, and then subsides within a few min.[8] Patients with PCH or primary LH, headache attacks predominantly affect bilateral, and posterior head regions but the location of pain may also be found in the frontal or temporal region or at the vertex.
Primary LH, PCH, and PEH may share some common pathogenesis. It has been speculated that the regions of the brain associated with the expression of mirth might be associated with LH.[5]
Earlier case reports[9] had documented the role of sodium valproate as an effective treatment in LH as well as in cough, headache, or other triggered headache syndromes. In our case also, it is an effective treatment option to prevent LH attacks.
ConclusionLH is a rare type of triggered headache which can share some similarities with PCH or PEH. In case of a high index of suspicion of LH, secondary causes should always be ruled out by a neuroimaging brain specifically focusing on the posterior fossa cranial structures. In the case of primary LH, avoidance of triggers, i.e., loud hearty laughter and prophylaxis with sodium valproate carries a favorable prognosis.
Declaration of patient consent
We hereby certify that we have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
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Conflicts of interest
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References
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