A Case Report - The Underlying Disease Behind Chronic Headache: More Than Just a Primary Headache?

Abstract

Chronic headache in adolescents is a diagnostic challenge due to overlapping primary and secondary causes. Lifestyle factors such as sleep deprivation or academic and psychosocial stress play an important role. An 18-year-old male presented to the neurology outpatient clinic on January 6, 2026, with a 2-year history of headache, worsening in the last year. The headache was described as band-like, moderate intensity, intermittent, lasting <1 minute, frequency 2 times per day. Sleep duration <6 hours/day. Physical and neurological examination was within normal limits: BP 119/84 mmHg, HR 88/min, BMI 19.03. Motor strength 5/5, physiological reflexes normal, pathological reflexes negative. A detailed clinical history revealed that the patient had recently been experiencing persistent feelings of guilt, with complaints consistently arising after masturbation. As his thinking matured, this also gave rise to anxiety regarding the potential impact on his reproductive system—specifically, a fear of becoming infertile. Uncontrollable urges to masturbate would arise sporadically. The patient is a fourth-semester university student who leads an active social and athletic life. These findings raised a suspicion of autonomic epilepsy, prompting appropriate supplementary examinations. A head CT scan showed mild cerebral edema, with no evidence of masses or hemorrhage. An EEG revealed diffuse abnormal irritative activity consistent with moderate-to-high voltage epileptiform discharges. Subsequently, the patient was managed as an autonomic epilepsy, and all complaints improved with treatment Folic Acid 1 mg once daily and Phenytoin 100 mg twice daily.Clinical features initially suggested tension-type headache. A more detailed and in-depth clinical history guides the performance of relevant supplementary examinations. However, abnormal EEG and mild cerebral edema require further evaluation to rule out secondary causes and comorbidities. Sleep deprivation may lower pain threshold and increase cortical excitability. Recurrent spontaneous autonomic impulses and abnormal EEG findings point to the occurrence of autonomic epileptic seizures. A mild cerebral edema on the head CT scan likely result from recurrent electrical brain activity associated with the seizures. Comprehensive biopsychosocial history and ancillary examinations are essential in chronic headache in adolescents. Incidental CT and EEG findings should be interpreted cautiously with clinical correlation.