(as it appeared in NHF Head Lines)

By Edmund Messina, MD
Medical Director
Michigan Headache Clinic
East Lansing, Michigan

As a neurologist who specializes in treating headaches, it is obvious to me how much sleep disorders are intimately connected to headache disorders. Most headache specialists agree that a wide range of sleep disorders can be found in the headache population. It is not uncommon to diagnose insomnia, excessive daytime sleepiness and sleep apnea in patients suffering from headache disorders.

Unfortunately, many of these disorders go unrecognized, so the purpose of this article is to help headache sufferers better understand the role of sleep in their headache disorder and how to best discuss these problems with their doctors.

INSOMNIA
Insomnia is a very common problem among headache sufferers. Some people are unable to fall asleep, while others cannot stay asleep. The American Academy of Sleep Medicine defines insomnia as difficulty initiating and maintaining sleep or sleep that is poor in quality. Poor quality sleep is basically nonrestorative. In our culture, it is common to see people “cheating” themselves out of enough sleep time. The average adult usually requires seven to eight hours of restorative sleep for optimal daytime functioning. Inadequate sleep, in quality or quantity, can increase the probability of headaches in addition to symptoms of poor concentration, sleepiness and irritability. It also increases the risks of traffic accidents or work accidents.

Inadequate nighttime sleep can be due to a person’s individual biology, but it also can be due to poor sleep hygiene. Poor sleep hygiene basically means that a person is engaging in habits that interfere with normal sleep. These habits may include daytime napping, variable bedtimes and waking times, and spending excessive amounts of time in bed with non-sleep activity. Poor sleep hygiene can also include the routine use of alcohol, nicotine or caffeine, particularly in the period preceding bedtime. It is also useful to avoid mentally and physically stimulating activities or emotionally upsetting activities too close to bedtime.

Insomnia can certainly be caused by factors unrelated to sleep hygiene. People with anxiety have trouble “shutting down” their thoughts and people with depression have problems initiating or maintaining their sleep. These problems need to be discussed with your doctor. Some people have difficulty getting to sleep when they undergo changes in their work shift or travel to different time zones. Many doctors recommend melatonin, an over-the-counter sleep-inducing agent, to normalize the sleep-wake cycle.

Oversleeping can be a headache trigger as well. This is commonly seen in teenagers who are essentially sleep deprived during the week and compensate by oversleeping on the weekends. The so-called “weekend headache” , which occurs on Saturday and Sunday mornings, is often explained by these variations of the sleep-wake cycle.

Of course, headaches can also be a sleep disruptor. Headaches, such as migraine, can wake people during certain stages of sleep or they may be apparent when a person wakes for other reasons. It is ironic that many of us will experience headache relief by “sleeping off a headache,” but many people are unable to sleep during a severe headache. Cluster headaches commonly wake sufferers, sometimes more than once in the night, and many patients report cluster attacks that occur at the same time each night. A rare disorder known as hypnic headache or “alarm clock headache,” which is seen in patients over age 50, occurs at exactly the same time each night. These are usually less severe than cluster headaches and can easily be treated with preventives, such as low-dose lithium.

When insomnia becomes a problem, patient and doctor need to spend time exploring the causes and strategies for treatment. Headache specialists recommend keeping a diary, which keeps track of your symptoms, triggers and response to medications, in order to determine patterns. It is particularly helpful if you also note your sleep patterns, such as sleep and wake times, and whether you feel refreshed after a night’s sleep. You may well see a correlation between poor sleep and headaches. You can also measure your degree of insomnia using the Insomnia Severity Index, a short questionnaire that may be available from your doctor’s office or downloaded from the internet.
Although sleep medications play a large role in the treatment of insomnia, they must be used wisely. Sleep medications are not intended to simply cover up other problems like those noted above.

EXCESSIVE SLEEPINESS
Excessive sleepiness can be a symptom of underlying abnormalities that can also worsen headaches. We already discussed the role of insomnia in causing daytime sleepiness, but there definitely are other causes. One of these is obstructive sleep apnea (OSA), a condition that can be potentially life-threatening and also can cause significant worsening of headache disorders.

For the sake of this discussion, we will define fatigue as a sensation of tiredness without the tendency to fall asleep. We will define sleepiness as a tendency to doze off during normal waking times. We will defer any discussions about narcolepsy, which can cause daytime sleep attacks or excessive daytime sleepiness, and concentrate upon more common causes of sleepiness.

Chronic sleepiness commonly leads to the use of caffeine to maintain daytime alertness—this is particularly troublesome for migraineurs. We know that migraine is a disorder of increased sensitization of the brain—sleep deprivation increases this hypersensitivity and the addition of caffeine further compounds the problem. Many headache remedies contain small doses of caffeine, but these are also the remedies that lead to medication-overuse headache when used excessively. Needless to say, excessive sleepiness can be dangerous while driving or operating machinery.
You can measure your degree of sleepiness by using the Epworth Sleepiness Scale, a short questionnaire that may be available from your doctor’s office or downloaded from the internet.

OBSTRUCTIVE SLEEP APNEA
Obstructive sleep apnea (OSA) is caused by a blockage of the airway during sleep and affects more than 12 million Americans, according to the National Institutes of Health. I frequently diagnose this illness in my chronic headache patients. It is an important diagnosis to make since sleep apnea can worsen underlying disorders such as diabetes, obesity and hypertension.

Although OSA can occur in any age group, gender or body build, it is more common in overweight people over the age of 40. Ironically, while weight gain can worsen OSA, OSA can also cause weight gain.

The diagnosis of OSA is very commonly missed, but one cannot stress enough the importance of uncovering and treating this condition. Although snoring is a very common symptom in OSA, the absence of snoring does not rule it out. The diagnosis is made with a nighttime sleep test known as a polysomnogram. These tests are administered in sleep centers, and a list of accredited sleep centers can be found on the American Academy of Sleep Medicine website (www.sleepcenters.org).OSA is usually treated by using a positive pressure mask, called CPAP, while sleeping. A very useful resource regarding this condition is the American Sleep Apnea Association (www.sleepapnea.org).

HOW TO TALK TO YOUR DOCTOR ABOUT SLEEP AND HEADACHES
Normalizing sleep-wake disorders is, then, a key element of improving headache care. Discussing your sleep patterns with your doctor is an important part of this process. It’s common that during a busy and sometimes hurried medical encounter, some symptoms may be overlooked. However, it is never acceptable to ignore sleep-wake disorders because of the dangers already discussed.

If you’re having trouble getting to sleep or staying asleep, you must first assure yourself that you are investing enough time each night (or day if you are a nightshift worker) . Next, you need to keep a sleep diary along with your headache diary. If insomnia is the major issue, download and fill out the Insomnia Severity Index questionnaire noted above. If daytime sleepiness is an issue, download and print out the Epworth questionnaire. If you would like to take a detailed medical history with an emphasis on sleep disorders, visit www.arbormedicus.com/pages/sleepiness.htm . You can print out a detailed report for your doctor or let him or her login to see it. This is a noncommercial site that also takes a detailed headache history.
Anyone with daytime sleepiness, especially if overweight or known to snore or wake up choking or gasping, is highly suspicious for obstructive sleep apnea and should be referred to a sleep lab for a polysomnogram.

In conclusion, sleep disorders and headache disorders go hand-in-hand and the successful treatment of headache often involves the successful treatment of sleep problems. Be sure you discuss these issues with your doctor.