Case presentation
A 19-year-old male engineering college student in good health (BMI 28) with no past medical, surgical, or illicit drug history presented in the clinic with a complaint of headache. It started around a year back, always event-related, and the last episode was 10 days back when he was attending a friends’ get-together. The patient observed that all these headaches precipitate acutely by a loud laugh, and while laughing, the headache builds up when the head naturally tilts back in a cervical extension position. It starts at the occipital-cervical region and spreads in a few seconds to involve the bilateral occipital region with a sense of grip accompanied by transient throbs lasting a few seconds or maybe a minute. The patient claims that he needs to suddenly quit his laugh at the peak of the laughing session as he senses some localized discomfort at the occipital region, which is not associated with any visual changes, giddiness, nausea, near fainting spells, tendency to fall, or any other bodily sensory or motor deficits. He tries to isolate himself from that humorous environment and sits/rests for a while, waiting for this headache to resolve on its own within a few minutes, and then he is back to normal without any residual effects.
The headache attacks were consistent with vigorous laughs and not related to Valsalva-like maneuvers or isolated neck bending or changing bodily position. The attacks were not reproducible if the intensity of the laugh was mild, and he claimed that humor inducted vigorous laugh serves as a good trigger for him. There were no associated symptoms suggesting migraine, cluster, or neuralgiform-type headache. He denies any continuous background headache or any form of ataxia. Also, there is no swallowing or chewing discomfort. Family members denied any chronic bothersome headaches or any other form of neurological disorders. The patient spends a good amount of time on his laptop (about 11-12 hours /day as work-related and mobile phone usage around 7-8 hours daily since the last two years), and he sleeps for about seven hours with no apnea or snoring.
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Neurological examination was unremarkable with equal reactive pupils. Sensory examination was normal. No local tenderness in neck muscle with no manipulative maneuver provoked pain recorded neither any palpable trigger points identified. Blood investigation and EEG were within normal range. MRI brain with cervical spine screening along with chamberlain and ryes line are within normal limit with non-congested posterior fossa as shown in Figure Figure1.1. No medicines were offered at this point. There was no clinical change after six months of follow-up. The patient agreed to follow up in the clinic if notices any new symptoms or changes in current symptoms.
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