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)

Since antiquity, evidence suggests that headacheis considered one of the most excruciating types ofpain, and can lead sufferers to attempt suicide, asreported in book XXV, chapter VII of NaturalHistory by Pliny the Elder (23-79 A.D.)1 Clusterheadache (CH) is a primary trigeminal–autonomicheadache classified as episodic (ECH) or chronic(CCH). Horton termed it “suicide headache” becausethe excruciating pain by which it is characterized canlead CH sufferers to consider suicide. An extremeexample has been cited: that of a CH patient who,suffering from chronic CH, during an unbearableattack fired a shotgun at his head. The available dataare quite variable. Suicidal ideation is reported tooccur amongst 55% of the CH population, althoughonly 2% admit actual suicide attempts. Jurgens et alreported 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 percent-ages reported by Robbins et al were 5.9% of CCHpatients and 6.3% of ECH without distinguishingbetween during or outside the bout.3 In addition,about half of CH sufferers would adopt potentially

self-injurious behaviors during attacks while attempt-ing any effort to stop the pain, even going so far as toworsen the situation and make it more dangerous tothemselves. Indeed, they may beat their heads, strikeobjects with their fists, or even bang their headsagainst a wall. Available data on CH triggering andaggravating factors are limited; the possible role ofgrief for the suicide of a beloved person as a potentialtrigger of a CH attack has never been reported.

In this correspondence, we report a 58-year-oldwoman who had a complete and uneventful medicalhistory, and who followed a healthy lifestyle; specifi-cally, she did not smoke nor drink alcohol. She came toour observation on June 20, 2012. Since the end ofApril 2012, she had suffered attacks of “an excruciat-ing pain, impossible to resist,” localized in the fronto-orbital and nasal regions on the right side,which lasted2 hours and recurred every day around 11:00 a.m.Attacks were accompanied by omolateral ptosis andrestlessness.This cluster, which had begun 3 days aftershe learned that the young son of a close friend hadcommitted suicide, ended only a few days before shecame to our practice for observation. A neurologicalexamination was normal.Cerebral MRI without gado-linium showed signs of chronic sinusitis in the maxil-lary, ethmoid, and sphenoid sinuses. In May, anotolaryngology (ORL) specialist had ruled out anycausal relationship with headache and treated sinusitiswith methylprednisolone 16 mg and antibiotics orally

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.

ISSN 0017-8748doi: 10.1111/head.12321

Published by Wiley Periodicals, Inc.Headache© 2014 American Headache Society

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for 10 days, during which the patient was asymptom-atic; headache reappeared the day after treatment wasdiscontinued. The patient had suffered a similarepisode in December 2011. This cluster, which lastedjust a week, had started 4 days after the news of thesuicide of a close friend. According to InternationalClassification of Headache Disorders criteria, ourpatient appeared to suffer from ECH. After a16-month follow-up, our patient did not present withfurther clusters nor experiences any major emotionalevents.Data available on CH patients are too scarce topermit making a list of triggers, such as has beenevidenced in migraine (M) and tension-type head-aches (TTH). Indeed, M and TTH patients are able torecognize several specific factors that could act astriggers: the most commonly reported include emo-tional stress, menses, weather changes, and disruptedsleep patterns. Hard drinking and/or smoking havebeen identified as high-risk behaviors that could berelated to CH attacks; however, it is significant thatthese conditions act as triggers only during the boutswhile they are ineffective in the period between clus-ters. More than half of CH patients are hard drinkers(65%) and recognize alcohol consumption as a triggerin the cluster period (53.8%).The vast majority of theCH population (73%) also present with a significanthistory of smoking.Furthermore,a recent head traumahas been reported as a possible cause of CH althougha definite relationship is difficult to prove. Conditionswhich lower blood oxygenation can trigger or compli-cate CH attacks: an association has been reported

between obstructive sleeping apnea and CH attacks.4

Other triggers are nitroderivatives, histamine, or vaso-dilators that can directly activate the trigeminal–vascular system. Our patient, however, never smokednor drank wine or spirits,nor was she exposed to any ofthe above-mentioned triggers.We did not find any dataon the potential role of emotional factors, more spe-cifically linked to the suicide of a beloved person, intriggering CH attacks. In our case, both clusters werestrictly related temporally to a grief of significantintensity. The apparent causal relationship betweenthe emotional impact of such tragic events and CH(also called “suicide headache”) episodes warrantsfurther investigation of the inverse possibility, ie, thatan extraordinarily stressful experience such as thesuicide of a beloved person, causing a shattered psy-chological 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. Impairmentin episodic and chronic cluster headache. Cephalal-gia. 2011;31:671-682.

3. Robbins MS, Bronheim R, Lipton RB, et al. Depres-sion and anxiety in episodic and chronic cluster head-ache: A pilot study. Headache. 2012;52:600-611.

4. Mitsikostas DD, Viskos A, Papadopoulos D. Sleepand headache: The clinical relationship. Headache.2010;50:1233-1245.

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