Headache and Sleep Disorders: Review and Clinical Implications for Headache Management

Jeanetta C. Rains, PhD; J. Steven Poceta, MD

Disclosures

Headache. 2006;46(9):1344-1363. 

In This Article

Abstract and Introduction

Abstract

Review of epidemiological and clinical studies suggests that sleep disorders are disproportionately observed in specific headache diagnoses (eg, migraine, tension-type, cluster) and other nonspecific headache patterns (ie, chronic daily headache, "awakening" or morning headache). Interestingly, the sleep disorders associated with headache are of varied types, including obstructive sleep apnea (OSA), periodic limb movement disorder, circadian rhythm disorder, insomnia, and hypersomnia. Headache, particularly morning headache and chronic headache, may be consequent to, or aggravated by, a sleep disorder, and management of the sleep disorder may improve or resolve the headache. Sleep-disordered breathing is the best example of this relationship. Insomnia is the sleep disorder most often cited by clinical headache populations. Depression and anxiety are comorbid with both headache and sleep disorders (especially insomnia) and consideration of the full headache-sleep-affective symptom constellation may yield opportunities to maximize treatment. This paper reviews the comorbidity of headache and sleep disorders (including coexisting psychiatric symptoms where available). Clinical implications for headache evaluation are presented. Sleep screening strategies conducive to headache practice are described. Consideration of the spectrum of sleep-disordered breathing is encouraged in the headache population, including awareness of potential upper airway resistance syndrome in headache patients lacking traditional risk factors for OSA. Pharmacologic and behavioral sleep regulation strategies are offered that are also compatible with treatment of primary headache.

Introduction

Sleep disorders occur disproportionately among headache patients, and both headache and sleep disorders are associated with significant psychiatric comorbidity. As described below, sleep disorders are disproportionately observed in specific headache diagnostic groups (ie, migraine, tension-type, cluster) and other headache patterns (ie, chronic daily headache, "awakening" or morning headache) irrespective of diagnosis. Interestingly, those sleep disorders associated with headache are varied in nature including breathing, movement, and circadian rhythm disorders as well as insomnia. In the absence of a sleep disorder, variations in sleep duration and schedule (oversleeping or undersleeping) are commonly identified headache triggers. These associations between sleep and headache are diverse in nature, but common to all is the dysregulation of sleep processes apparently impacting headache threshold.

Similar psychiatric disorders are comorbid with both headache and sleep disorders. As detailed elsewhere in this volume and the accompanying Headache journal supplement devoted to Psychiatric Comorbidity,[1,2,3,4,5,6] affective disorders occur with at least 3-fold greater frequency in migraineurs than that in the general population, and the prevalence increases in clinical populations, especially with chronic daily headache.[7] Sleep disturbance (increased or decreased sleep) is a diagnostic symptom of a number of psychiatric disorders,[8] and occurs in the majority of patients with depression, anxiety, and chemical dependencies.[9,10,11] Most often the sleep complaint is "insomnia" but the complaint of "hypersomnia" occurs as well. Sleep disturbance is believed to be an important precipitating or premonitory symptom of affective disorders, because prospective longitudinal studies have observed sleep disturbance to precede and predict the onset of later psychiatric symptoms by years.[12,13,14]

The association of headache, sleep, and psychiatric disorders likely stems from related pathogenic processes.[15] Consideration of the full headache-sleep-affective symptom constellation may yield opportunities to impact headache threshold and maximize treatment. The process for the regulation of sleep in headache management includes: identification and treatment of primary sleep disorders, management of insomnia with or without concurrent affective illness, and optimizing the schedule, duration, and quality of sleep. This paper reviews the nature and magnitude of comorbidity between headache and sleep disorders through relevant epidemiological and clinical prevalence studies (including psychiatric symptoms where available), clinical implications for headache evaluation, sleep screening strategies, identification of primary sleep disorders, and behavioral sleep regulation strategies for the primary headache patient.

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