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Sleep and Headache Disorders

Jeanetta Rains, PhD

Jeanetta Rains, PhD, is Clinical Director of the Center for Sleep Evaluation at Elliot Hospital in Manchester, NH. She is Fellow of: American Board of Sleep Medicine; American Academy of Sleep Medicine; American Headache Society. She has been working in the field of headache and sleep disorders medicine since 1991, including patient care, education of medical and psychology residents and fellows, and research.

The association between headache and sleep disorders was recognized well over a century ago and the last quarter century has brought a marked growth in this literature. Historically, the literature was comprised primarily of anecdotal observations, small descriptive reports and single-group treatment outcome studies. The literature is maturing with an increased number of empirical and prospective studies. Interestingly, the earliest volumes of the journal Headache included astute observations of sleep involvement in cluster and migraine headache,1 pediatric headache,2 and psychiatric comorbidity.3 Dexter and Riley4 published one of the earliest EEG studies correlating nocturnal headaches with specific sleep stages and processes. Later experimental studies have provided strong evidence for chronobiological patterns in cluster and migraine headache5-10, as well as hypnic headache. Time-series analyses and controlled studies have supported early observations of sleep-related headache triggers.11-13 Dysregulation of sleep (e.g, sleep deprivation, oversleeping, disturbed or interrupted sleep) is now recognized as one of the more commonly reported acute headache triggers among patients with migraine and tension type headache.
Chronic daily headache not otherwise specified or a pattern of awakening frequently with any headache, termed “awakening headache,” is the headache descriptor most often used in this literature and most often associated with a sleep disorder. Obstructive sleep apnea is the sleep disorder most often associated with headache14-18 although conflicting reports have been presented. For example, Idiman and colleagues16 found headache was not related to sleep apnea severity (i.e., apnea/hypopnea index, minimum oxygen saturation) in a non-headache sample of patients with sleep apnea. ‘Sleep apnea headache’ is the only formal diagnosis for headache secondary to a sleep disorder recognized by the International Classification of Headache Disorders-2nd Edition [ICHD-II]. Among clinical headache populations, obstructive sleep apnea has been identified in a sizeable percentage of patients with cluster, hypnic, and other chronic headache diagnoses refractory to standard care. There are reports that treatment of sleep apnea improved or resolved headache in at least a subset of patients,18 but there are no controlled trials.

Headache has been linked to a wide range of sleep disorders in adults,19-20 adolescents21 and children.22 Among patients with migraine and tension type headache, insomnia is the most common sleep complaint, reported by one-half to two-thirds of headache clinic patients. One of the largest clinical studies published to date reported sleep complaints among 1,283 migraineurs presenting for headache treatment.20 Morning headaches were reported by 71% of migraineurs. Though insomnia was not systematically assessed, the majority of patients reported difficulty initiating sleep (53%) and maintaining sleep (61%). Chronically shortened sleep patterns suggestive of insomnia were observed in 38% of migraineurs (< 6 hours sleep per night) and shorter sleep was associated with greater migraine frequency and severity.

Sleep complaints have been identified as risk factors for frequent and severe headache conditions.23-26 In a United Kingdom cross sectional study, Boardman24 identified a dose-response relationship between headache severity and sleep complaints (i.e., trouble falling asleep, wake up several times, trouble staying asleep, or waking after usual amount of sleep feeling tired or worn out). Among 2662 respondents, headache frequency was associated with slight [age/gender adjusted OR=2.4 (1.7-3.2)], moderate [OR=3.6 (2.6-5.0)], and severe [OR=7.5 (4.2-13.4)] sleep complaints.[12] The study also identified an association with anxiety.

A common clinical scenario is for episodic headache to “transform” to chronic headache over the span of months or years. It has been postulated that migraine, chronic daily headache, and perhaps other forms of chronic headache are progressive disorders.25-26  Sleep-related variables including snoring, insomnia, daytime sleepiness, circadian rhythm disorders and parasomnias have been identified as potential risk factors for chronic headache.23-26  Thus, sleep and other modifiable risk factors may become clinical targets for headache prevention.27

Psychiatric disorders are comorbid with both headache and sleep disorders.23,28-30 Affective disorders occur with at least three-fold greater frequency in migraineurs than in the general population, and the prevalence increases in clinical populations, especially with chronic daily headache.28 Sleep disturbance (increased or decreased sleep) is a diagnostic symptom of a number of psychiatric disorders, and occurs in the majority of patients with affective disorders. Most often the sleep complaint is “insomnia” but the complaint of “hypersomnia” occurs as well.

Recent studies have controlled for psychiatric disorders. Sleep disturbance in headache patients is not explained solely by the presence of a psychiatric disorder29 and insomnia is an independent risk factor for chronic headache.23,30

Several papers have been published offering recommendations for evaluation and treatment of sleep-related headache.31-33 While at the present time there are no evidence-based guidelines for clinical practice, these recommendations draw broadly from the scientific literature and take into consideration the full constellation of headache-sleep-mood symptoms commonly encountered in more severe and complex headache conditions. While there have been precious few controlled treatment studies, a recent randomized controlled trial34 has demonstrated marked improvement in chronic migraine following a behavioral sleep intervention with headache change proportionate to the number of sleep behaviors changed (dose-response relationship)—providing compelling evidence for sleep regulation in chronic headache sufferers.

The relationship between sleep and headache disorders and the association with mood/anxiety disorders implicates common neuro-anatomic systems. Expert reviews of mechanisms have been published recently in Headache.35-36 It is expected that the next decade of empirical research will yield prospective and controlled studies of sleep related headache that may not only facilitate clinical management but possibly yield measures to prevent or limit progression to chronic headache. 

Classic Contributions in Headache
1. Graham JR. Cluster headache. Headache. 1972;11(4):175-85.
2. Choa D, McGovern JP, Haywood TJ, Knight JA. Headaches in children: The Migraine syndrome. Headache. 1963;3(1):13-20.
3. Diamond S. Depressive headaches. Headache. 1964;4:255-9.
4. Dexter JD, Riley TL. Studies in nocturnal migraine. Headache. 1975;15(1):51-62.

Chronobiological Patterns in Headache
5. Terzaghi M, Ghiotto N, Sances G, Rustioni V, Nappi G, Manni R. Episodic cluster headache: NREM prevalence of nocturnal attacks. Time to look beyond macrostructural analysis? Headache. 2010;50(6):1050-4.
6. Alstadhaug K, Salvesen R, Bekkelund S. 24-hour distribution of migraine attacks. Headache. 2008;48(1):95-100.
7. Vetrugno R, Pierangeli G, Leone M, Bussone G, Franzini A, Brogli G, D'Angelo R, Cortelli P, Montagna P. Effect on sleep of posterior hypothalamus stimulation in cluster headache. Headache. 2007;47(7):1085-90.
8. Soriani S, Fiumana E, Manfredini R, Boari B, Battistella PA, Canetta E, Pedretti S, Borgna-Pignatti C. Circadian and seasonal variation of migraine attacks in children. Headache. 2006;46(10):1571-4.
9. Fox AW. Time-series data and the "migraine generator". Headache. 2005;45(7):920-5.
10. Fox AW, Davis RL. Migraine chronobiology. Headache. 1998;38(6):436-1.

Sleep-Related Headache Triggers
11. Alstadhaug K, Salvesen R, Bekkelund S. Insomnia and circadian variation of attacks in episodic migraine. Headache. Sep 2007;47(8):1184-1188.
12. Chabriat H, Danchot J, Michel P, Joire JE, Henry P. Precipitating factors of headache. A prospective study in a national control-matched survey in migraineurs and nonmigraineurs. Headache. 1999;39(5):335-8.
13. Spierings EL, Sorbi M, Maassen GH, Honkoop PC. Psychophysical precedents of migraine in relation to the time of onset of the headache: the migraine time line. Headache. 1997;37(4):217-220.

Sleep Apnea Headache
14. Pelin Z, Bozluolcay M. Cluster headache with obstructive sleep apnea and periodic limb movements during sleep: a case report. Headache. 2005;45(1):81-3.
15. Graff-Radford SB, Newman A. Obstructive sleep apnea and cluster headache. Headache. 2004;44(6):607-10.
16. Idiman F, Oztura I, Baklan B, Ozturk V, Kursad F, Pakoz B. Headache in sleep apnea syndrome. Headache. 2004;44(6):603-6.
17. Paiva T, Batista A, Martins P, Martins A. The relationship between headaches and sleep disturbances. Headache. 1995;35(10):590-6.
18. Poceta JS, Dalessio DJ. Identification and treatment of sleep apnea in patients with chronic headache. Headache. 1995;35(10):586-9.

 Sleep Disturbance In Headache: Descriptive Reports of Adult, Adolescent, and Pediatric Patients
19. Calhoun AH, Ford S, Finkel AG, Kahn KA, Mann JD. The prevalence and spectrum of sleep problems in women with transformed migraine. Headache. 2006;46(4):604-10.
20. Kelman L, Rains JC. Headache and sleep: examination of sleep patterns and complaints in a large clinical sample of migraineurs. Headache. 2005;45(7):904-10.
21.Gilman DK, Palermo TM, Kabbouche MA, Hershey AD, Powers SW. Primary headache and sleep disturbances in adolescents. Headache. 2007;47(8):1189-94.
22. Miller VA, Palermo TM, Powers SW, Scher MS, Hershey AD. Migraine headaches and sleep disturbances in children. Headache. 2003;43(4):362-8.

Sleep-Related Risk Factors for Chronic Headache (“Chronification”)
23. Sancisi E, Cevoli S, Vignatelli L, Nicodemo M, Pierangeli G, Zanigni S, Grimaldi D, Cortelli P, Montagna P. Increased Prevalence of Sleep Disorders in Chronic Headache: A Case-Control Study. Headache 2010;50(9):1464-72.
24. Boardman HF, Thomas E, Millson DS, Croft PR. Psychological, sleep, lifestyle, and comorbid associations with headache. Headache 2005;45(6):657-69.
25. Bigal ME, Lipton RB. Modifiable risk factors for migraine progression (or for chronic daily headaches)—clinical lessons. Headache. 2006;46(Suppl 3):S144-6. 26. Scher, AI, Midgette, LA, Lipton, RB. Risk Factors for Headache Chronification. Headache 2008;48(1):16-25.
27. Rains, JC. Chronic Headache and Potentially Modifiable Risk Factors: Screening and Behavioral Management of Sleep Disorders. Headache 2008;48(1):32-9.

Psychiatric Comorbidity
28. Lake AE, Rains JC, Penzien DB, Lipchik GL. Headache and Psychiatric Comorbidity: Historical Context, Clinical Implications, and Research Relevance. Headache 2005;45(5): 493-506.
29. Vgontzas A, Cui L, Merikangas KR. Are sleep difficulties associated with migraine attributable to anxiety and depression? Headache. 2008;48(10):1451-9.
30. Boardman HF, Thomas E, Millson DS, Croft PR. Psychological, sleep, lifestyle, and comorbid associations with headache. Headache. 2005;45(6):657-69.

Screening and Treatment of Sleep Disorders in Headache Patients
31. Mitsikostas DD, Viskos A, Papadopoulos D. Sleep and headache: the clinical relationship. Headache. 2010;50(7):1233-45.
32. Silberstein SD, Dodick D, Freitag F, Pearlman SH, Hahn SR, Scher AI, Lipton RB. Pharmacological approaches to managing migraine and associated comorbidities—clinical considerations for monotherapy versus polytherapy. Headache. 2007;47(4):585-99.
33. Rains JC, Poceta JS. Headache and sleep disorders: review and clinical implications for headache management. Headache. 2006;46(9):1344-63.
34. Calhoun AH, Ford S. Behavioral sleep modification may revert transformed migraine to episodic migraine. Headache. 2007;47(8):1178-83.

Shared Mechanisms of Headache and Sleep Disorders
35. Evers S. Sleep and headache: the biological basis. Headache. 2010;50(7):1246-51.
36. Dodick DW, Eross EJ, Parish JM, Silber M. Clinical, anatomical, and physiologic relationship between sleep and headache. Headache. 2003;43(3):282-92.

 Virtual Issue compiled online 4 November 2010

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