Pauline Anderson

June 26, 2017

AMSTERDAM — Patients with migraine, especially chronic migraine, are at increased risk for sleep disturbances, including sleep apnea (SA), a new study suggests.

About 37% of patients with migraine responding to a survey were deemed to be at high risk for  SA, which is much higher than estimates in the general population.

And because over 75% of migraine respondents with SA were diagnosed by a physician, "it may be worthwhile to start asking our patients about this," said Dawn C. Buse, PhD, a licensed clinical psychologist and associate professor, Department of Neurology, Albert Einstein College of Medicine of Yeshiva University, New York City.

"We haven’t tested this yet, but the hope is that if sleep apnea is associated with more frequent headaches, treating sleep apnea might benefit headache."

Dr Buse, who is also director of behavioral medicine for the Montefiore Headache Center in New York City, presented the new results from the Chronic Migraine Epidemiology and Outcomes (CaMEO) study at the Congress of the European Academy of Neurology (EAN) 2017.

Both depression and anxiety have a bidirectional relationship with migraine, Dr Buse told delegates. Such a relationship also exists in sleep disorders; sleep disorders can aggravate migraine and migraines can worsen sleep disorders.

Researchers recruited participants from an online panel by using quota sampling. Survey invitations were sent to 16,763 CaMEO study respondents, of whom 12,810 provided valid data.

Researchers divided participants into those with episodic migraine (EM) and those with chronic migraine (CM) on the basis of headache frequency; headache on 15 or more days a month was considered CM. The analysis included 11,699 participants with EM and 1111 with CM.

Chronic vs Episodic

Participants were typical of online survey populations, said Dr Buse. For example, their average age was about 42 years.

But there were some differences between the EM and CM groups. For example, the CM group contained more women, and, not surprisingly, said Dr Buse, those with EM were significantly more likely to be employed. "Also not surprising was that our CM folks are more likely to have a high BMI [body mass index]," she said.

Participants completed baseline and 3-month follow-up surveys now to over 1.5 years.

Risk for SA was assessed as high or low by using the Berlin Scale for Sleep Apnea.  On the basis of this scale, 37.0% of respondents were at high risk for SA (EM, 35.6%; CM, 51.8%; P < .001).

This risk for SA "is quite high compared population estimates," which can be as low as 9%, commented Dr Buse.

The risk changes across BMI categories, she noted. In men, for example, "you see for people with EM that these rates just skyrocket from 11% for those who are underweight to 18% for those who are normal weight, to 35% for the overweight and 79% for the obese."

Rates for women followed the same pattern, although their risks were consistently lower than those among men.

Sleep apnea risk for the patients with CM also rose with increasing BMI. Their risk was even higher in the obese category, in which nearly 92% of men and 84% of women were at high risk for SA.

Participants self-reported whether a physician had ever diagnosed them with SA. Among those with SA, 75.7% reported a physician diagnosis (EM, 74.7%; CM, 82.8%).

When asked whether they were currently using continuous positive airway pressure or another breathing device, 35% with EM and 32% of those with CM said they were.

Dr Buse stressed that she and her colleagues did not interview the participants or obtain medical records.

The researchers looked at various indices of sleep — including snoring, daytime somnolence, and sleep adequacy — by using responses to the Medical Outcomes Study Sleep Scale.

"Our patients with CM fare worse on all indices," commented Dr Buse. She added that 50% of CM participants met criteria for sleep disturbances compared to 38% of those with EM and that nearly 40% of those with EM felt their sleep was adequate compared to 34% of CM participants.

On average, patients with EM got 6.8 hours of sleep per night and those with CM got 6.4 hours. About 55% of those with EM and 41% with CM said they get enough sleep.

She reminded her audience about the importance of sleep hygiene, of keeping the same sleep and wake times, limiting devices in the bedroom, and considering exercise and relaxation.  

Questioned by a delegate about a recent study indicating that 6 hours of sleep daily may be sufficient, Dr Buse said she had not heard of this research but stressed that sleep quality — as well as quantity — is important, especially for people with SA.

"They may have the same time into and out of bed, but have less sleep quality, or there may be some other factors that affect their migraine."

Session chair Stefan Evers, MD, PhD, professor of neurology, Department of Neurology, University of Münster, Germany, asked which type of sleep apnea — obstructive or central — the patients with migraine had. He noted that a study of his that used polysomnography found that central sleep apnea was "more prominent" than obstructive apnea in these patients.

"I believe that central mechanisms are more important than just obesity or obstructive mechanisms," he said.

The Berlin questionnaire doesn't differentiate type of sleep apnea, said Dr Buse. "But from a mechanistic point of view, that could be very important because we often say, 'lose weight and that will solve your problem'."

The study was funded by Allergan.

Congress of the European Academy of Neurology (EAN) 2017. Abstract O1109. Presented June 24, 2017.

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