Abstract
Chittaranjan Andrade, Bangalore, India:
I present a case of multimodal hallucinations with zolpidem and suggest that the presence of vascular headache, or the use of the drug in paediatrics, may increase the risk of this adverse effect.
Ms N, a 13-year-old, 46 kg, psychiatrically healthy girl, had a 2-year history of occasional vascular headaches rapid in onset, unilateral throbbing in nature and accompanied by nausea.
Late one evening, N developed severe headache. Her father administered paracetamol (acetaminophen; 500 mg) and zolpidem (5 mg); the former to relieve pain, the latter to help her sleep.
Within 15 minutes N developed drowsiness, confusion, unsteadiness and a feeling that the world was swimming around her. She lay down but this offered little relief. As the minutes ticked by, the experiences became more bizarre. She felt she was sailing in a ship, her pillow was sliding up, her bed was sliding down, and she was suspended in mid-air. The phenomena appeared to be kinesthetic hallucinations. N tried to rise, but failed to coordinate her body and fell heavily on the floor.
Her mother helped her back into bed. A few minutes later, visual hallucinations began. These were Lilliputian in nature and comprised little men running around the room and on her bed. Her mood was one of fear and doubt.
Just before she fell asleep, insight dawned. ‘I'm not really on a ship, am I? and I can't really be seeing those little men, can I? But they're there, I'm really seeing them. Even now.’ The picture qualified for a DSM-IV diagnosis of a substance-induced delirium. The period from ingestion of medication to falling asleep lasted about half an hour. When N awoke the next morning, she was completely well. She continued to experience occasional headache, but without complication.
Since N had used paracetamol uneventfully and frequently for previous headache, it is unlikely that this was responsible for her distressing experience. There is good reason to implicate zolpidem, it can induce ataxia and hallucinations as frequent and infrequent effects, respectively [1].
While transient or prolonged visual or other hallucinations with zolpidem may be rare, concurrent therapy with selective serotonin reuptake inhibitors may increase the risk [2]. This case suggests that vascular headache, and the use of zolpidem in children may also increase the risk. The possible interaction between zolpidem and vascular headache is worth considering because vascular headache may itself be associated with hallucinatory phenomena, especially visual [3].