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Migraine is highly prevalent in the pediatric population, with findings from population-based studies indicating rates of 7.7%–9.1% among children and adolescents. 1 Sleep disorders are also frequently observed in these groups and represent a common comorbidity in pediatric patients with migraine. Reports of increasing sleep impairment and migraine prevalence in pediatric populations in recent years highlight the need to elucidate the nature of the relationship between these conditions.
“The cerebral structures, networks, and neurochemical systems that are involved in the genesis of migraine align closely with those responsible for the regulation of sleep,” suggesting a shared pathophysiology between migraine and sleep disorders, according to a review published in Pediatric Neurology.1 For example, the hypothalamus, cortex, and brainstem have been identified as critical structures in both sleep physiology and migraine pathophysiology, while shared neurochemical systems include melatonin, adenosine, orexin, and calcitonin gene-related peptide.
Numerous studies have demonstrated a bidirectional relationship between sleep disorders and migraine throughout childhood and adolescence. Disturbed sleep in infancy was shown to predict the development of headache during childhood, with a 2015 meta-analysis noting that infants with a history of colic were over 5 times more likely to develop migraine compared to those with no colic history (odds ratio [OR], 5.6; 95% CI, 3.3—9.5; P =.004).2 Additionally, sleep impairment has been cited as one of the most common triggers in pediatric migraine.1
Other findings have shown associations between various non-rapid eye movement (NREM) parasomnias and migraine in children. A survey of parents of 100 pediatric migraineurs revealed substantially higher rates of several disorders compared to controls: night terrors (77% vs 11%), sleep walking (55% vs 16%), and nocturnal enuresis (41% vs 16%).1 In a 2019 retrospective study of 185 children with migraine, polysomnography revealed high prevalence rates of obstructive sleep apnea (40%), insomnia (27%, and periodic limb movement disorder (15%).3
A 2012 case-control study found that the prevalence of restless legs syndrome (RLS) was 22% in children and adolescents with migraine compared to 5% among those who did not have migraine (P <.001).4
Nonpharmacologic sleep-based interventions have demonstrated efficacy in treating pediatric migraine. In an earlier study of pediatric migraineurs with poor sleep hygiene, those who received sleep hygiene instruction showed significant reductions in the mean duration and frequency of migraine compared to controls.5 Other research has found reductions in headache frequency and improved sleep quality in adult and adolescent patients with migraine and tension-type headache who received psychological sleep interventions.6 In a 2018 study, 70.5% of adolescent migraineurs with comorbid insomnia demonstrated at least 50% reduction in headache frequency and improvement in insomnia following completion of a cognitive behavioral intervention of 6 sessions and a follow-up booster session.1
The authors recommend that clinicians conduct a detailed sleep history on patients with migraine, and polysomnography should be obtained as indicated. All patients should receive instruction regarding optimal sleep hygiene. Assessment of serum ferritin levels is recommended, along with iron supplementation of 3-4 mg/kg/d in migraineurs with symptoms of RLS with serum ferritin levels <50 ng/mL. Melatonin therapy may be considered for both migraine prophylaxis and insomnia. Additional approaches that may be offered to address migraine and sleep disorders include cognitive behavioral therapy, meditation, biofeedback, and hypnosis.1
To further discuss the sleep-migraine connection in pediatric patients, we interviewed Marcy Yonker, MD, director of the Pediatric Headache Program at Children’s Hospital Colorado in Aurora, and professor of clinical practice in the Department of Pediatrics-Neurology at the University of Colorado School of Medicine and Michelle Clementi, PhD, licensed psychologist at the Pediatric Headache Program at Children’s Hospital Colorado and assistant professor in the Department of Psychiatry at the University of Colorado School of Medicine.
What does the evidence show regarding the associations between migraine and sleep in children and adolescents?
It is known that children aged 2-12 with migraine have a higher prevalence of sleep disorders.7 Studies of circadian patterns in children with migraine show peaks in the early morning (P =.002) and afternoon (P <.001). with a peak between November and January, suggesting an association with school.8 It is likely that inadequate sleep is a strong trigger for migraine during the school year.
Teenagers tend to have a delayed sleep phase, there appears to be a predominant biological preference for falling asleep later and waking up later in this age group. It is frequently observed in clinical practice that when teens are allowed to sleep in during holidays, their migraine frequency spontaneously decreases. However, schools have been slow to respond to studies suggesting that high schools should have later start times.
There is also likely a bidirectional relationship between sleep and migraine – migraine can cause sleep problems such as difficulty falling asleep due to pain, while inadequate sleep can trigger migraine. The hypothalamus regulates sleep and is known to activate up to 24 hours before a migraine headache. It is likely that this forms the basis of the relationship between sleep and migraine, but the details are not completely understood thus far.
How should these issues be addressed in clinical practice in terms of screening, prevention, and treatment?
Questions relating to sleep hygiene should always be a part of a comprehensive headache evaluation. It is important for physicians to ask not just about sleep duration but about sleep quality as well. Educating families about the importance of sleep in managing migraine is key. If a significant sleep disturbance is found, addressing this with pharmacologic or behavioral sleep interventions may help reduce the patient’s headache burden significantly.
If sleep problems are particularly resistant to treatment, a request to accommodate a later school start time for the patient might be warranted. This should only be a short-term solution while working with a professional such as a sleep specialist or psychologist to regulate sleep. During the transition from summer break to the school year, encourage families to gradually move to an earlier bedtime in the weeks before school starts so children and teens don’t experience a sudden change in sleep patterns. Combined with the stress commonly associated with the beginning of the school year, a drastic shift in sleep can worsen migraine.
Cinicians should encourage children and teens to practice healthy sleep hygiene. This includes going to bed and waking up around the same time every day, limiting daytime naps, getting adequate sunlight and exercise during the day, and reducing use of electronics in the bedroom. Encourage patients to use their bed only for sleep – no homework, watching videos, or scrolling through social media in bed. By limiting other activities in bed, this will strengthen the brain’s association between the bed and sleep, which can help reduce the time it takes to fall asleep at night.
Teens are especially tempted now to follow a “24/7” lifestyle with regards to electronics use, which can cause significant sleep disruption. A family rule could be set to have all family members’ cellphones and other electronic devices stored in one location out of the bedroom after a certain time each evening.
What are other important recommendations for clinicians to help optimize outcomes for these patients?
Sleep difficulties often co-occur with anxiety and depression, which can maintain or worsen migraine episodes.9 It is important to screen children and teens for frequent anxiety and sad or irritable mood. If there are concerns about anxiety or depression, connecting the patient with a psychologist can help both sleep and as well as mood and emotional concerns, which will ultimately help migraine management.
If prophylactic medication is being considered for treatment of migraine, using an agent which may aid sleep, such as amitriptyline, may be helpful for both migraine prevention and treatment of insomnia. School districts should also consider pushing back start times for teens, as this would result in better school attendance and performance for migraineurs.
What should be the focus of future investigation regarding the link between pediatric migraine and sleep?
There needs to be better understanding biologically of how sleep deprivation can trigger migraine, as this may provide insight into underlying mechanisms and broaden the options for both pharmacologic and behavioral therapy. The sleep-migraine relationship can be strongly impacted by mental health and development (for example, the onset of puberty). There is still much to be understood about how these different factors are all interrelated. The more clearly we understand these complex relationships across childhood and adolescence, the more targeted our interventions can be.
Longitudinal studies are also needed to understand how sleep can affect migraine across childhood development. For example, could early sleep problems be a risk factor for developing migraine later in life? This could be important for identifying prevention approaches. Most studies examining sleep in children ask kids or parents to report on the child’s sleep. However, we know that that self-reported sleep often does not align well with objective measures of sleep. More studies using objective measures such as polysomnography or actigraphy are needed.
References
1. Pavkovic IM, Kothare SV. Migraine and sleep in children: a bidirectional relationship [published online February 11, 2020.]. Pediatr Neurol. doi:10.1016/j.pediatrneurol.2019.12.013
2. Gelfand AA, Goadsby PJ, Allen IE. The relationship between migraine and infant colic: a systematic review and meta-analysis. Cephalalgia. 2015;35(1):63‐72.
3. Armoni Domany K, Nahman-Averbuch H, King CD, et al. Clinical presentation, diagnosis and polysomnographic findings in children with migraine referred to sleep clinics. Sleep Med. 2019;63:57‐63.
4. Seidel S, Böck A, Schlegel W, et al. Increased RLS prevalence in children and adolescents with migraine: A case-control study. Cephalgia. 2012; 32(9):693-9.
5. Bruni O, Galli F, Guidetti V. Sleep hygiene and migraine in children and adolescents. Cephalalgia. 1999;19 Suppl 25:57‐59.
6. 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.
7. Miller VA, Palermo TM, Powers SW, Scher MS, Hershey AD. Migraine headaches and sleep disturbances in children. Headache. 2003;43(4):362‐368.
8. Soriani S, Fiumana E, Manfredini R, et al. Circadian and seasonal variation of migraine attacks in children. Headache. 2006;46(10):1571‐1574.
9. American Migraine Foundation. Sleep disorders and headache. https://americanmigrainefoundation.org/resource-library/sleep/ Updated April 8, 2019. Accessed online June 10, 2020.
