The Symbiosis of Headache and Sleep

Patients with headache often experience sleep disturbances and vice versa. Neurology Advisor spoke with 2 experts in sleep and headache — Jelena M. Pavlovic, MD, PhD, attending neurologist at Montefiore Headache Center in New York City, and Angeliki Vgontzas, MD, a clinical headache fellow at the John R. Graham Headache Center of Brigham and Women’s Faulkner Hospital in Boston, Massachusetts — about the clinical implications of these comorbid disorders.

Neurology Advisor: There appears to be bidirectional correlation between headache and sleep disorders. Is this simply a cause-and-effect mechanism or do they share an etiology?

Jelena M. Pavlovic, MD, PhD: Headache as a symptom has certainly been commonly implicated as a byproduct of “poor sleep.” Some headache disorders, such as hypnic headache, are directly related to sleep and others, such as cluster headache, have a very strong relationship with sleep through shared biological mechanisms. However, these headache disorders are infrequent and a majority of patient complaints in neurology practice are related to sleep dysfunction in the setting of migraine and vice versa.

Angeliki Vgontzas, MD: Migraine in particular shares a complex and poorly understood relationship with sleep. Patients report poor sleep prior to migraine attacks as well as during them. We often tell patients to try to work on their sleep hygiene and to get enough sleep in case it may be a migraine trigger. On the other hand, many people find that going to sleep terminates a headache attack. The more we learn about sleep and migraine, the more the data point toward a common etiology as well and not just a cause-effect relationship.

Neurology Advisor: Studies have indicated that different types of headaches produce variations in sleep disturbances.^1-3 Can you elaborate?

Dr Pavlovic: Cluster headache is perhaps the best-known headache disorder to disrupt sleep with an attack. Cluster headache shows an interesting rhythmicity that we still do not quite understand. Patients tend to get attack periods during a certain time of year, and the specific attacks occur during certain parts of the day, frequently waking them up from sleep at night. It is likely that the brain centers involved in our wake/sleep rhythms are involved in cluster headache as well. For migraine, the relationship is not quite as clear and we tend to see less characteristic disruption of sleep with a migraine attack; however, this still occurs in a certain percentage of patients and appears to increase with age.

Other types of rare headache disorders are unique to sleep, such as hypnic headache, which manifests as a nocturnal headache in which patients (typically older) tend to wake up all of a sudden with a headache several hours after falling asleep. This can occur many times a week, without occurring during the day. Sleep apnea can also cause people to have nighttime headaches, which further disrupts their sleep.

Neurology Advisor: The combination of sleep deprivation or inadequate sleep quality and headache pain can trigger a chronic cycle. Can you break the cycle merely by improving sleep? What types of interventions do you recommend?

Dr Pavlovic: One approach to this cycle of (often) daily headaches is to stabilize sleep in the hope that removing the presumed headache trigger will stabilize headaches. Another is to treat headache with a preventive therapy with the hope that stabilization of the headache will help improve sleep dysfunction as well. A third approach, and one commonly employed in clinical practice, is to use a modality—such as tricyclic antidepressants—that has an effect on sleep and headache in order to improve both simultaneously. 

Dr Vgontzas: If you are chronically losing sleep, you cannot simply make up a certain number of hours (ie, “sleep debt”). When you deprive yourself of sleep (willingly or not), there are changes in various stress and inflammatory markers in your body. Studies show that even when you allow yourself to recover by getting more sleep afterward, those changes do not revert immediately.^4,5

Neurology Advisor: A 2015 study by Chiu et al⁶ linked obstructive sleep apnea to a higher risk of developing tension type headache. Have you seen a similar correlation?

Dr Vgontzas: As headache specialists, we routinely screen our patients for symptoms of sleep apnea. Sleep apnea headache is a specific diagnosis that occurs temporally with the onset of sleep apnea, requires an objective diagnosis of sleep apnea (via polysomnography), and significantly improves or remits with successful treatment of sleep apnea.⁷ Snoring is more common in patients with migraine as well (as noted by Scher et al⁸), although epidemiologic studies are not picking up a particularly increased prevalence of sleep apnea in patients with migraine.⁹

Dr Pavlovic: Headache disorders and sleep apnea are quite common in the general population and we wonder if people with underlying headache disorders are more sensitive to the headache-inducing effects of sleep apnea (several studies have shown that hypoxemia — such as that occurring with sleep apnea — can induce a headache).¹⁰ It is interesting to think of sleep apnea as a potential inciting factor for primary headache disorders. However, the most important clinical aspect is to identify those at risk for sleep apnea and to refer to a sleep specialist who can diagnose and begin appropriate treatments.

Neurology Advisor: How should a clinician screen for possible overlapping sleep and headache disorders?

Dr Pavlovic: Most available screening tools are focused on either sleep or headache. There are several easy-to-use screening tools such as the “Stop-Bang” tool for sleep apnea or the Epworth Sleepiness Scale to assess daytime sleepiness (an indicator of poor nighttime sleep). However, the most important thing is to systematically ask patients about their sleep. We like to ask a few questions with regard to snoring and difficulty with getting to sleep or staying asleep. If a patient confirms that this is happening, then we would want to get a sense of the severity and impact on their daytime function. If there is suspicion of a sleep disorder, we have a low threshold to refer to a sleep specialist.

Dr Vgontzas: Patients with headache are typically asked to keep a 3-month headache diary in order to best evaluate their headache patterns and potential headache triggers. Patients can be advised to track their headaches and sleep to see if patterns emerge. Certainly educating patients about their headache and sleep patterns, as well as potential trigger avoidance and encouraging them to follow up on concerning symptoms is an integral part of care in these situations. 

References

1. Rains JC, Davis RE, Smitherman TA. Tension-type headache and sleep. Curr Neurol Neurosci Rep. 2015;15(2):520.
2. Fernández-de-Las-Peñas C, Fernández-Muñoz JJ, Palacios-Ceña M, et al. Sleep disturbances in tension-type headache and migraine. Ther Adv Neurol Disord. 2017;11:1756285617745444.
3. Engstrøm M, Hagen K, Bjørk MH, Stovner LJ, Sand T. Sleep quality and arousal in migraine and tension-type headache: the headache-sleep study. Acta Neurol Scand Suppl. 2014;198:47-54.
4. Lasselin J, Rehman JU, Åkerstedt T, Lekander M, Axelsson J. Effect of long-term sleep restriction and subsequent recovery sleep on the diurnal rhythms of white blood cell subpopulations. Brain Behav Immun. 2015;47:93-99.
5. Basner M, Rao H, Goel N, Dinges DF. Sleep deprivation and neurobehavioral dynamics. Curr Opin Neurobiol. 2013;23(5):854-863.
6. Chiu YC, Hu HY, Lee FP, Huang HM. Tension-type headache associated with obstructive sleep apnea: a nationwide population-based study. J Headache Pain. 2015;16:34.
7. Suzuki K, Miyamoto M, Miyamoto T, et al. Sleep apnoea headache in obstructive sleep apnoea syndrome patients presenting with morning headache: comparison of the ICHD-2 and ICHD-3 beta criteria. J Headache Pain. 2015;16:56.
8. Scher AI, Lipton RB, Stewart WF. Habitual snoring as a risk factor for chronic daily headache. Neurology. 2003;60(8):1366-1368.
9. Russell MB. Sleep apnea headache: a growing concern in an increasingly obese population? Expert Rev Neurother. 2013;13:1129-1133.
10. Lagman-Bartolome AM, Gladstone J. Metabolic headaches. Neurol Clin. 2014;32(2):451-469.