Authors: Paik W.
Source: Medscape UK, January 12, 2026.
Summary
This Medscape case report describes a 75-year-old man with a long-standing, refractory form of exploding head syndrome (EHS), a parasomnia characterized by sudden, loud noise perceptions during sleep onset or transitions, often accompanied by fear and transient sleep paralysis. For more than five years, the patient experienced frequent episodes several times per week, described as lightning-like sensations radiating through the body, thunder-like sounds, brief paralysis, and intense terror lasting approximately 10 seconds per episode. The symptoms occurred primarily at sleep onset but occasionally caused nocturnal awakening.
Despite extensive neurologic and psychiatric evaluation, no structural or epileptiform cause was identified. MRI showed only mild microvascular changes, EEG was normal, and polysomnography demonstrated preserved sleep architecture with no evidence of sleep-disordered breathing or other parasomnias. Multiple medication trials—including NSAIDs, triptans, beta blockers, tricyclic antidepressants, muscle relaxants, gabapentin, valproate, amitriptyline, and buspirone—were unsuccessful or only minimally effective.
Given the refractory nature of symptoms, sublingual ketamine was initiated at 25 mg every third night and subsequently escalated to nightly dosing. The patient reported a progressive and sustained reduction in symptom frequency and severity over several months, with near-complete resolution of exploding head syndrome by six months of treatment. Only occasional sleep paralysis persisted, and overall sleep-related fear and quality of life markedly improved.
The authors propose that ketamine’s NMDA receptor antagonism and modulation of cortical excitability may play a role in alleviating EHS symptoms, particularly in patients unresponsive to conventional therapies. While this represents a single-case experience, it highlights ketamine as a potential option for otherwise treatment-resistant parasomnias.
Key Points
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Exploding head syndrome can be chronic, distressing, and refractory despite benign neurologic findings
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Extensive imaging, EEG, and sleep studies may be normal despite severe symptoms
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Conventional agents for headache, mood, and neuropathic pain may fail in chronic EHS
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Sublingual ketamine was associated with marked symptom reduction and eventual resolution in this case
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Ketamine may represent a potential option for severe, treatment-resistant EHS, though evidence remains limited
What You Should Know
In patients with long-standing, refractory parasomnias causing significant distress and sleep avoidance, alternative neuro-modulatory strategies may warrant consideration after exclusion of structural, epileptic, and primary sleep disorders. This case suggests ketamine could be a future option in highly selected patients, but broader studies are needed before routine adoption.
Thank you for allowing us to highlight this Medscape case feature, which draws attention to a novel and potentially meaningful therapeutic approach for a rare but impactful sleep disorder.