Patients With Headache May Also Have Posttraumatic Stress and Sleep Disorders

Allison Gandey

July 06, 2010

July 6, 2010 (Los Angeles, California) — Posttraumatic stress and sleep disorders are among the most prevalent comorbidities in patients with headache, report researchers. Presenting here at the American Headache Society 52nd Annual Scientific Meeting, experts outlined what to watch for.

"It's important that we keep these comorbidities in mind and target everyone," session moderator Robert Nicholson, PhD, from the Ryan Headache Center at St. Louis University in Missouri, said during an interview. "It's not uncommon for patients to have a significant anxiety disorder or trouble with sleep, and this will have an impact on treatment."

Presenter Dawn Buse, PhD, from the Albert Einstein College of Medicine in the Bronx, New York, pointed out that headache patients with posttraumatic stress disorder often have greater disability.

She said that structural and functional changes in the brain appear to occur over time. "Posttraumatic stress has been linked to dysfunction of the autonomic system, hypothalamic-pituitary-adrenal axis, and serotonin modulation," she noted. "Chronic low levels of serotonin and norepinephrine have been implicated in both posttraumatic stress and migraine."

Presenter Jeanetta Rains, PhD, from the Center for Sleep Evaluation at Elliot Hospital in Manchester, New Hampshire, pointed out that such neurobiological changes may also influence sleep.

Table 1. Percentage of Headache Patients Affected by Triggers in Recent Studies

Trigger Kelman Scharff et al Robbins
Stress 80 72 62
Sleep disturbance 50 52 31

Data are from Kelman. Cephalalgia. 2007;27:394-402; Scharff et al. Headache. 1995;35:397-403; and Robbins. Headache. 1994;34:214-216.

Dr. Dawn Buse

"The prevalence of sleep disorders tends to increase as headaches become more frequent and severe," Dr. Rains said. She suggested that headache may improve with the treatment of sleep. "All headache sufferers — especially episodic migraine and tension type — may benefit from the inclusion of sleep variables in headache trigger management."

Dr. Rains said that patients with a so-called awakening headache are at high risk of having a comorbid sleep disorder. "An awakening headache or pain that wakes the patient up should be considered a red flag."

Screening is key, Dr. Nicholson told Medscape Neurology. "But it's also important that we know what we don't know and consider referral when appropriate."

For comorbid psychiatric disorders, Dr. Rains recommends clinicians use brief questionnaires such as the Beck Depression Inventory for primary care, the Beck Anxiety Inventory, or the Generalized Anxiety Disorder 7-Item Scale.

For clinicians looking to assess posttraumatic stress, Dr. Buse recommends the Veterans Affairs screening tool. "This was adopted due to its brevity and sensitivity," she said. "It was developed and validated for use in primary care settings, for example."

Dr. Buse also recommends the Veteran Affairs and Department of Defense Clinical Practice Guideline for the Management of Post Traumatic Stress. For more information, please see the following: Veterans Affairs screening tool, Practice Guidelines, and International Society for Traumatic Stress Studies (information and educational videos).

Dr. Dawn Buse has received funding from Allergan, Endo, Merck, MAP, and Iroko Pharmaceuticals. Dr. Robert Nicholson and Dr. Jeanetta Rains have disclosed no relevant financial relationships.

American Headache Society (AHS) 52nd Annual Scientific Meeting: Concurrent Symposia 1. Presented June 26, 2010.

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