Sleep Disorders and Headache
Jeanetta C. Rains, PhD
Center for Sleep Evaluation at Elliot Hospital, Manchester, NH
Disrupted sleep regulation may contribute to headache disorders, such as migraine, tension-type,
cluster, and chronic daily headache. Across studies, headache sufferers exhibit a two- to eight-fold
greater risk for sleep disorders than the general population, and the prevalence of sleep disorders
tends to increase as headaches become more frequent and severe.¹ Chronic daily or morning headache
patterns, regardless of diagnosis, are particularly suggestive of sleep disorders. Most often implicated
are obstructive sleep apnea, insomnia, and circadian phase abnormalities. The comorbidity of sleep and
headache disorders is believed to have its basis in neuroanatomical connections and neurophysiological
mechanisms, involving especially the hypothalamus, serotonin, and melatonin.² Treatment literature
demonstrates that a significant proportion of sleep apnea-related headaches will improve or resolve
with treatment of apnea¹ and preliminary evidence suggests transformed migraine may improve with
behavioral insomnia treatment.³ Clinicians are encouraged to identify and treat sleep disorders that
may improve or resolve headache.
Screening tools aid identification of sleep disorders in headache patients
Headache evaluation should include at least a brief sleep history, examining headache activity in relation
to the sleep/wake cycle. Polysomnography is necessary to diagnose sleep apnea, hypersomnias, and
parasomnias, while the diagnosis of insomnia is generally based on history. Screening tools assist
in identifying patients warranting formal testing.¹ Diagnostic sleep interviews may be cued by simple
mnemonics such as REST (Restorative nature of sleep, Excessive daytime sleepiness, tiredness
or fatigue, the presence of habitual Snoring, and whether the Total sleep time is sufficient). A sleep/
headache diary is particularly helpful in assessing insomnia and sleep-related headache triggers.
Specific headache patterns are suggestive of a sleep disorder
Irrespective of diagnosis, chronic daily, morning or “awakening” headache patterns may signal a sleep
disorder. Awakening headache occurs in 4% to 6% of the general population, 18% of insomniacs, and
15% to 74% of sleep apneics across studies.¹ The best evidence linking awakening headache with a
specific sleep disorder is in the case of obstructive sleep apnea. Sleep apnea headaches may present
as awakening headache or as migraine, tension type, cluster or unclassifiable headaches.
Treatment of sleep disorders may improve or resolve headache
Sleep disorders most implicated with headache include obstructive sleep apnea, primary insomnia,
and circadian phase abnormalities. Treatment of the sleep disorder, especially obstructive sleep
apnea, can improve and in some cases resolve headache.¹,² Patients may be assessed for traditional
symptoms (for example, habitual snoring, witnessed apnea, hypersomnia or insomnia, night sweats,
nocturia) and risk factors (for example, obesity, male gender, increasing age, craniofacial/oral/
neuromuscular factors that diminish size or patency of the airway, chronic alcohol, sedatives, hypnotics,
or muscle relaxants). Suspected cases warrant referral for polysomnography to diagnose and calibrate
treatment efforts to disease severity, symptoms, and comorbidities. Primary treatments for sleep
apnea include weight loss, treatment of nasal allergies, positional treatment for supine-related apnea,
upper airway surgery, oral appliances for mandibular advancement, and continuous positive airway
pressure.¹ Because of the potential for headache to improve, re-evaluation of headache is advised
one-month following treatment of sleep apnea.
Sleep regulation may improve headache
Insomnia is the most common sleep complaint in headache clinic populations, observed in half to
two-thirds of patients.¹ Insomnia refers to a history of recurrent difficulty with onset, maintenance,
duration or quality of sleep despite an adequate opportunity to sleep. Insomnia results in daytime
impairment, usually fatigue or sleepiness, or other somatic, cognitive or emotional complaints.
Symptoms may be quantified with the sleep-headache diary or questionnaires.¹ Recent evidence
suggests behavioral sleep modification may reduce headache. Behavioral sleep therapy includes:
(1) Schedule consistent bedtime that allows 8 hours time in bed; (2) Eliminate TV, reading, music in
bed; (3) Use visualization technique to shorten time to sleep onset; (4) Move supper >4 hours before
bedtime; limit fluids within 2 hours of bedtime; (5) Discontinue naps. In a randomized controlled trial
of patients with transformed migraine, this behavioral sleep intervention yielded a significant reduction
in headache frequency and intensity relative to the sham treatment control group.³ Headache
improvement was proportionate to the number of sleep behaviors changed. Thus, a relatively brief
behavioral sleep intervention may favorably impact headache outcomes.
1. Rains JC, Poceta JS. Headache and sleep disorders: Review and clinical implications for
headache management. Headache 2006;46(9):1344-1361.
2. Dodick DW, Eross EJ, Parish JM. Clinical, anatomical, and physiologic relationship between
sleep and headache. Headache 2003;43(3):282-292.
3. 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):604-610.
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