Psychological Interventions for Comorbid Migraine and Sleep Dysfunction

Researchers found data that showed, regardless of the number of headaches reported in addition to insomnia that cognitive behavioral therapy is indicated as first-line treatment.

Migraine and insomnia are both common disorders, with prevalence estimates of 12% and 10% in the United States, respectively.1,2 A substantial body of research shows that the 2 conditions are linked in numerous ways and suggests a bidirectional relationship. In a 2018 meta-analysis of 85 articles with a total of 27,122 participants, sleep issues were identified as the second most common trigger for migraine and tension-type headache (odds ratio, 0.41; 95% CI, 0.36-0.47) after stress.3

“People with migraine have a higher prevalence and worsened severity of sleep disorders such as insomnia than people without migraine, and sleep disturbances may decrease the migraine threshold, trigger migraine, increase the risk of migraine chronification, and increase healthcare utilization,” Mia Tova Minen, MD, MPH, chief of headache research and assistant professor in the departments of neurology and population health at NYU Langone Medical Center, New York City, told Neurology Advisor. “Sleep disorders are more prevalent in people with chronic migraine than with episodic migraine. However, episodic migraine is associated with insomnia.”

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In a retrospective cross-sectional study published in May 2018 in Pain Medicine, Dr Minen and colleagues examined migraine and sleep characteristics of 61 new patients suspected of having migraines based on their responses to the intake questionnaire, which included the Insomnia Severity Index.4 The findings revealed a mean headache frequency of 11.6 days per month, and 49.2% of patients had Insomnia Severity Index scores indicating clinical insomnia (≥15). Factors linked to higher Insomnia Severity Index scores included depression (Spearman rho [rho] =.610), general anxiety (rho =.436), and musculoskeletal pain (18.7 vs 13.8; P =.027).

Cognitive behavioral therapy for insomnia (CBT-I) is a first-line treatment that has been found to increase rapid eye movement sleep and nonrapid eye movement sleep in affected individuals.5 “Given the strong association between comorbid musculoskeletal pain, depression, anxiety, and insomnia, we suggest prioritizing CBT-I referral for those patients regardless of their headache frequency,” Dr Minen and colleagues concluded.4

This approach was one of the psychological treatment strategies for insomnia that were examined in a recent review published in Scientific Reports.5 The authors explain that the close connection between headache and sleep impairment may result from dysregulation in shared brain regions. The ventrolateral periaqueductal gray (vPAG) is one of the regions “responsible for switching off [rapid eye movement] sleep, and…[when] stimulated with orexin, the vPAG has an inhibitory effect on nociception” in the trigeminal nucleus caudalis (TNC), which is the “main area of the brainstem responsible for the sensation of head pain,” they wrote. “Indeed, with the hypothalamus’ responsibility for sleep-wake rhythms, dysregulated sleep in general may disrupt hypothalamic signalling to the vPAG, potentially explaining the link between various issues with sleep dysregulation and headache activity.”

The 4 studies that met criteria for inclusion in their review are summarized here.

  • A randomized controlled trial published in 2007 investigated the effects of a behavioral sleep modification intervention in 43 women with transformed migraine.6 Compared with placebo (sham behavioral intervention), the behavioral sleep modification group showed significant reductions in headache frequency [F(1,33=12.42; P =.001)] and headache intensity [F(1,33=14.39; P =.01)]; 48.5% of these participants had reverted to episodic migraine by the time of the final follow-up visit.
  • A 2009 observational cohort study used a 9-week intervention consisting of sleep hygiene counseling and oral prazosin at bedtime in 126 veterans with blast-induced mild traumatic brain injury.7 At baseline, common comorbidities included frequent, severe headaches and neurological deficits, and only 5 of the veterans with these comorbidities reported restful sleep. Postintervention, restful sleep was reported by 65 veterans, and peak headache pain decreased from 7.28±0.27 to 4.08±0.19 on a 0 to 10 scale (values presented as mean±standard deviation). Headache frequency decreased from 12.40±0.94 to 4.77±0.34 per month, and scores on the Montreal Cognitive Assessment improved from 24.50±0.49 to 28.60±0.59. These improvements were sustained at the 6-month follow-up.
  • A parallel-arm pilot randomized controlled trial published in 2016 examined the effects of CBT-I compared with a sham intervention in 31 adults with co-occurring chronic migraine and insomnia.8 At the 6-week follow-up, reductions in headache frequency were observed in both groups (48.9% vs 25.0%), with CBT-I showing greater reductions than control treatment. In addition, CBT-I “produced significantly larger increases than control treatment in total sleep time and sleep efficiency as quantified by actigraphy, as well as in self-reported insomnia severity,” and treatment adherence was high.
  • A 2018 single-arm pilot trial evaluated the feasibility and acceptability of CBT-I for 21 adolescents with co-occurring chronic migraine and insomnia.9 After an intervention consisting of 6 sessions over the course of 6 to 12 weeks, with a booster session 1 month later, CBT-I participants demonstrated improvements in headache days (M=4.7 [SD=2.1] vs M=2.8 [SD=2.7]) and insomnia symptoms (M=16.9 [SD=5.2] vs M=9.5 [SD=6.2]), and these changes were sustained at the 3-month follow-up (M=2.7 [SD=2.8]; M=9.3 [SD=5.0], respectively). Improvements in pain-related activity limitations, sleep hygiene, and sleep quality were also noted.

Although this is an emerging area of research requiring further investigation, the findings thus far suggest that psychological interventions such as CBT-I may have significant value for patients with comorbid headache and sleep disorders.

“It would be good to have studies evaluating CBT-I for migraine patients with insomnia who also have comorbid depression, anxiety, and/or chronic pain, as these comorbidities are also known to be associated with insomnia,” said Dr Minen. In addition, there is a need for research focusing on the dissemination of CBT-I in formats that can be used across large populations, considering the high prevalence of insomnia. “There are electronic versions of CBT-I that might prove beneficial to these patients, and we need more studies to see if they can help people with migraine, including those with associated comorbidities.”


1. Migraine Research Foundation. About migraine. Accessed June 28, 2019.

2. Roth T. Insomnia: definition, prevalence, etiology, and consequences. J Clin Sleep Med. 2007;3(suppl 5):S7-S10.

3. Pellegrino ABW, Davis-Martin RE, Houle TT, Turner DP, Smitherman TA. Perceived triggers of primary headache disorders: A meta-analysis. Cephalgia. 2018;38(6):1188-1198.

4. Begasse de Dhaem O, Seng E, Minen MT. Screening for insomnia: an observational study examining sleep disturbances, headache characteristics, and psychiatric symptoms in patients visiting a headache center. Pain Med. 2018;19(5):1067-1076.

5. Sullivan DP, Martin PR, Boschen MJ. Psychological sleep interventions for migraine and tension-type headache: a systematic review and meta-analysis. Sci Rep. 2019;9(1):6411.

6. Calhoun AH, Ford S. Behavioral sleep modification may revert transformed migraine to episodic migraine. Headache. 2007;47(8):1178-1183.

7. Ruff RL, Ruff SS, Wang X. Improving sleep: initial headache treatment in OIF/OEF veterans with blast-induced mild traumatic brain injury. J Rehabil Res Dev. 46(9):1071-1084.

8. Smitherman TA, Walters AB, Davis RE, et al. Randomized controlled pilot trial of behavioral insomnia treatment for chronic migraine with comorbid insomnia. Headache. 56(2):276-291.

9. Law EF, Wan Tham S, Aaron RV, Dudeney J, Palermo TM. Hybrid cognitive-behavioral therapy intervention for adolescents with co-occurring migraine and insomnia: a single-arm pilot trial. Headache. 2018;58(7):1060-1073.