(as it appeared in NHF
By Edmund Messina, MD
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
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 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
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
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.
Additional information about sleep and headaches is available
More information about sleep apnea can be found