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I am looking for help in taking a next step in trying to figure out what is wrong with me.
History
Reasonably fit 29yr old male. Traditionally poor diet and gain weight when not exercising.
GERD medication (currently Pantoprazole) for approx 10yrs.
About 8yrs ago I got very overweight 110kg and developed stretch marks on my abdomen and a round face and hips. Currently 88kg.
Slight urinary incontinence after I finish urinating.
Have to ‘jiggle' my legs when seated.   
I always have cold and clammy hands and feet.
My resting HR used to be between 50-60 and my BP was around 75/130.
I have always drunk a lot of caffeine. This spiked about 6 months back when I started playing an online game and was staying up all night – I basically had a steady stream of it all night – coffee and coke. I quit the game a few months back as work was suffering (I work for myself) and gave up caffeine.
Symptoms
Currently, every time I try and sleep, right on the verge of sleep, I jerk violently awake.   
Over the past few months the jerks have been getting worse . The jerks seem to have changed in nature. This is how I described them just over a month ago
“It feels like a burst of adrenaline and then, a short time later, I experience fatigue similar to how I feel after having had a massive adrenaline burst. This includes a general fatigue and a slightly ‘spaced out' feeling in the top of my head. I also have an ‘empty' feeling in my chest and slight shortness of breath that may just be because I am scared to breath. Sometimes right after the jolt it feels like my pulse is racing as I can feel my heart pounding – BUT, when I take my pulse, it is normal for me at between 50-60. I have had hypnic jerks before and they seem completely different to these. I don't think I have anxiety or stress. The episodes happen maybe 4-7 nights of the week and it doesn't seem to matter how tired I am. Perhaps the worst thing about them is the ‘spaced out' feeling I get in my head which can last for hours afterwards and makes it difficult to concentrate or even get back to sleep.”
I think the adrenaline bursts may have been ‘secondary' to the jerks and my body's response to being jolted on the verge of sleep.
I now get these jolts every single time I try and go to sleep and would speculate that they seem to be jolts from my head, around the temple. I also don't get quite as bad an ‘adrenaline' come down in terms of weakness afterwards. I feel almost like my body has run out of adrenaline or I have gotten so used to the jerks that I don't get the bursts of it anymore.
My reflux was getting worse and I was taking antacids in addition to the PPIs. I was also getting a feeling of pressure in my upper abdomen, just below the sternum. I assume this was coming from my stomach as, on standing, I burp a lot and it seem to relieve this somewhat. I feel like my stomach might be slowly filling with air as I breath when I lie down.
I have drastically changed my diet and worked on my fitness so I can stop using PPIs in case they were causing any of my symptoms. I now take them rarely, the pressure still comes and I still burp a lot (possibly from inhaling air?) but I don't get as much, if any, acid reflux.
When I initially went to the doctor he did some tests which showed my liver function was normal, blood glucose was normal and a catecholamines 24hour urine test showed a high score but still within normal range. He basically said I was fine after these results came back.
Continued on next block.
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Answered in 1 hour by:
9/18/2010
Dr. Arun Phophalia
Category: Medical
Satisfied Customers: 38,437
Experience: MBBS MS. Post doctoral fellowship in Sports Medicine. General surgeon and sports medicine specialist
Verified

Greetings.

I am sorry that your question was unanswered for long.

Sleep starts are a normal phenomenon occurring in persons of all sexes and all ages with a prevalence of 70%. They presumably arise from sudden descending volleys that originate in the brainstem reticular formation and are activated by the instability of the system at the transition between wake and sleep. Only occasionally do they become excessive, and, in most cases, subside spontaneously, without any treatment. So you should not be worried. Sleep starts are also called as hypnic jerks.

Hypnic jerks are common and has been experienced by almost everyone at one time or another. Only on occasion are the hypnic jerks excessive and bothersome to the individual. If the jerks are excessive prior to sleep, the other causes to consider would be;

1) periodic and aperiodic involuntary movements that are relatively commonly seen in patients with RLS (restless leg syndrome). In a minority of patients with RLS, these movements may be more prominent than the leg discomfort and may be very rapid or myoclonic in speed. In some cases, these very rapid movements in RLS patients during wakefulness electrophysiologically show the characteristics of propriospinal myoclonus, which is initiated by nerve fibers of spinal cord origin.

According the new International Classification of Sleep Disorders, sleep starts (hypnic jerks) are characterized as follows: sudden brief jerks at sleep onset, mainly affecting the legs or arms; and the jerks are associated with at least one condition from among a subjective feeling of falling, a sensory flash, or a hypnagogic dream. In addition, the disorder must not be better explained by another sleep disorder, medical or neurologic disorder, mental disorder, medication use, or substance use disorder

Thus you should not be worried, though you may consider getting an EEG, sleep study, and other investigations to look for the causes of restless leg syndrome (RLS). Restless legs syndrome (RLS) is a common cause of sleep disruption. The sensations associated with RLS are given many different names such as creepy, crawly, electric, or painful. RLS can develop as a result of certain conditions or factors, particularly iron deficiency and peripheral neuropathy. Other causes are folate or magnesium deficiency, amyloidosis, diabetes mellitus, lumbosacral radiculopathy, or vitamin B-12 deficiency. Thus following other investigations are advised;

1) A complete iron panel including iron levels, ferritin, transferrin saturation, and total iron binding capacity.

2) BUN,

3) creatinine,

4) magnesium,

5) thyroid-stimulating hormone (TSH),

6) vitamin B-12, and folate.

Following measures would be helpful;

1) Avoidance of caffeine, alcohol, or nicotine (if take them, you have already stopped caffeine which will help you).

2) Exercise before the bed time

3) Relaxation exercises

4) Yoga

5) Medications if RLS;

a) Pramipexole (Mirapex)

b) Ropinirole hydrochloride (Requip).

For profound hypnic jerks; Occasional Benzodiazepines.

Please feel free for your follow up questions.

Dr. Arun

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Customer reply replied 7 years ago

Thank you for that - I really appreciate the time you put in and will undertake to get those tests. I actually had a second related enquiry that got cut off as I had written too much. It is perhaps a more immediate problem:

In a bid to get healthy I have been (for the last month or so) exercising as much as twice a day (playing squash, running, swimming, tennis) and eating well - with only one cup of coffee first thing in the morning. I went from around 92-93kg to 88kg and gained a bit of muscle mass to boot. I have also been taking a B vitamin complex and magnesium supplements. I did this in case it was my diet that was the issue; to try and exhaust myself so I could sleep; to get of PPIs; and to help relieve any possible anxiety. Obviously the symptoms have persisted.

Then , 2 days ago I went to the gym for the first time in about 6 months. I did a really intense interval programme, all body exercises lifting as heavy as I could (because I thought I was pretty fit). I then hopped in the sauna and then an icy cold shower (as I've done many times before). Pretty stupid in hindsight. I thought I was going to collapse, my vision was not only double or triple but going rapidly back and forward in front of my face. My muscles, especially my left pectoral muscle was spasming or had really bad tremor (it was going nuts). I wasn't sure if it was my heart or not. Someone took my pulse and it was about 130 (which I get to only by really pushing myself and certainly not after a workout is over and I've been sitting in the sauna relaxing). I felt dizzy and like I was about to collapse.

Someone took me to the emergency dept at the hospital where a doctor came and saw me - he did an ecg, glanced at it and said I was good to go and that he wasn't going to do anything else for someone as young and fit as me. He said it was just the blood vessels dilating and constricting from the combination of hot and cold that was a classic recipe for collapse (I didn't actually fully collapse but felt like I was about to).

The worst thing now is that there is a pressure in my head that is really bad at my temples. The pressure is still crazy in my head as I write this (2 days later) and I hope it is just still some exercise induced migraine.

I have had what was diagnosed eventually as a migraine only once before around 2 years ago. The doctor originally thought it might be a TIA as I had no history of migraine but it lasted for around 7 days and so she (this was my old doctor who died - I recently have a new one) said it was a migraine.

I can't remember if I had this crazy pressure but it could be much the same thing.

I have been taking ibuprofen and paracetemol pretty constantly for god knows how long (but not at above the recommended dosages). It doesn't really seem to relieve the pressure in my head. I also feel pressure behind my nose and right eye (and the vision feels a little funny). I want to keep staring at one spot and have difficulty concentrating (it is taking a lot of fear induced effort to type all this). The pressure comes and goes - it seems to be relieved somewhat when I sit at a 45% position in bed.

Should I be worried about this?

Hello,

I feel, you should not be worried about it, especially when you EEG was alright. Again a stress and anxiety can be read between your lines. I feel, you have gone through lot of internet sites for the diagnosis and that can play in your mind. I do not feel that it can be a brain tumor or anything serious like that, but if you feel that, and this will completely relax you, you may talk to your doctor and get an MRI of the brain. With all your description, I am not worried, but many times investigations are done, for ruling out, remotest of the thing. Once MRI is normal, trivial symptoms will play less in mind and that helps in spontaneous remission of all these things.

It is pleasure and privilege assisting you.

Dr. Arun

Dr. Arun Phophalia
Category: Medical
Satisfied Customers: 38,437
Experience: MBBS MS. Post doctoral fellowship in Sports Medicine. General surgeon and sports medicine specialist
Verified
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