Altered Melatonin Secretion and Recurrent Sleep-Related Headache in a Patient With a Pineal Cyst: A Case Report

Melatonin contributes to the circadian regulation of sleep and nociception, and disruption of its secretion has been implicated in headache disorders with nocturnal periodicity.The functional relevance of pineal cysts in this context remains poorly defined.A 23-year-old woman presented with a four-year history of stereotyped headaches occurring exclusively between 1:30 and 4:00 a.m. and awakening her from sleep.The attacks were occipital-suboccipital, pulsating and pressure-like, rated 7/10 in intensity, and accompanied by scalp allodynia, bilateral conjunctival hyperemia and lacrimation, mild nasal congestion, and restlessness.Neurologic examination and investigations for secondary causes were unremarkable.Serial brain magnetic resonance imaging (MRI) demonstrated a benign-appearing pineal cyst measuring initially 21 × 11 × 10 mm, without hydrocephalus, obstruction of cerebrospinal fluid pathways, or aggressive radiologic features.Two melatonin measurements obtained at 3:00 a.m. were reduced at 14 and 16 pg/mL against a laboratory reference range of 40-80 pg/mL.Treatment with oral melatonin at 4 mg nightly reduced the headache symptoms by approximately 50% within four weeks.Increasing the dose to 8 mg nightly was followed by complete resolution within six weeks.After three months, the nocturnal melatonin concentration was 52 pg/mL, and the patient remained headache-free without reported adverse effects at the six-month follow-up.This case demonstrates a temporal association among nocturnal headaches, reduced nocturnal melatonin secretion, and improvement following melatonin supplementation.Although a single case cannot establish causality, assessment of circadian hormone secretion may be considered in selected patients with pineal lesions and strictly nocturnal headaches.