Elsevier

Disease-a-Month

Volume 61, Issue 6, June 2015, Pages 240-248
Disease-a-Month

Headaches and sleep disorders

https://doi.org/10.1016/j.disamonth.2015.03.008Get rights and content

Introduction

Sleep disorders and headache are common and often occur in the same patient, but the nature of this relationship is not completely understood.1 The prevalence of migraine has been reported as 13.2% in the United States, 8.6% were male and 17.5% were female.2 Most studies estimate that between 3% and 4% of the population have chronic daily headache (worldwide 1–10.5% among adults).3

The prevalence of obstructive sleep apnea is estimated at 4–5% of the middle-aged people, and sleep-disordered breathing may affect up to 20%.4 Studies show from 2.0% to 18.9% prevalence of restless legs syndrome in Americans (variation likely depending on how it is defined).5 Chronic insomnia is estimated to affect 10–15% of the population.6 Transient insomnia may occur in approximately one-third of the population.7 It would be expected by chance that some people with headache disorders also have sleep problems. However, studies have shown a strong association between sleep and headache, although this association is complex and not well understood.8 The occurrence of sleep disorders is greater among those who have headache disorders than those who do not.9

Headache could be the result of disrupted nocturnal sleep or events that take place during sleep, such as the hypoxia or hypercapnia that occurs in obstructive sleep apnea, resulting in morning headaches.10 Sleep disruption may be the result of a primary headache disorder as in arousals due to hypnic headaches.11 Sleep disturbance and headache might both be manifestations of a similar underlying pathogenesis due to hypothalamic dysfunction, leading to migraine premonitory symptoms and sleep disturbance.12 Any of these could occur depending on the headache and sleep disorder involved.

Section snippets

ICSD-III

The history of formal classification of sleep disorders begins with the Diagnostic Classification of Sleep and Arousal Disorders (DSCAD) published in 1979. The next classification system was the International Classification of Sleep Disorders (ICSD) published in 1990 and revised in 1997. This offered compatibility with the International Classification of Disease (ICD-9). The next system was the ICSD-II introduced in 2005.13

The latest classification of sleep disorders, International

Relationship between sleep and headache

The relationship between sleep and headache has been studied at least since the 19th century.15 In particular, headaches upon awakening, morning headache, and chronic daily headache indicate the possibility of sleep disorders. Sleep disorders most commonly associated are obstructive sleep apnea, primary insomnia, and circadian rhythm abnormalities.16 There is a paradoxical relationship, in which sleep deprivation or excess can lead to worsening headaches, but sleep onset can relieve an ongoing

Insomnia and headache

Insomnia is defined as a persistent difficulty with sleep initiation, duration, consolidation, or quality, which occurs despite adequate opportunity and circumstances for sleep, resulting in some form of daytime impairment.14 In a large population-based epidemiological review, Uhlig et al. found that primary headaches including migraine and tension-type headache were significantly related to insomnia symptoms. Odds ratio (OR) estimates ranged from 1.4 to 1.7. In patients with frequent,

Sleep-related breathing disorder and headache

The sleep-related breathing disorders are characterized by abnormalities of respiration during sleep.14 Studies show relation between headaches and sleep apnea, but not consistently. Headaches and morning headaches are common in patients with sleep apnea and snoring, and the treatment with nasal continuous positive airway pressure leads to an improvement in the sleep apnea patients.33, 34, 35 Habitual snoring was also associated with morning headache in a study of 268 patients done by Chen et

Central disorders of hypersomnolence and headache

Daytime sleepiness is defined as the inability to stay awake and alert during the major waking episodes of the day, resulting in periods of irrepressible need for sleep or unintended lapses into drowsiness or sleep.14 Excessive sleepiness can occur in patients with headache. In a case–control study of 100 episodic migraine patients, Barbanti et al.51 demonstrated increased sleepiness compared to matched patients without migraine. This was also shown in chronic migraine.52 There is a higher

Circadian rhythm sleep–wake disorders and headache

Circadian rhythm sleep–wake disorder is defined as alteration of the circadian time-keeping system, its entrainment mechanisms, or a misalignment of the endogenous circadian rhythm and the external environment.14 Periodicity of headache attacks and disruption of biorhythms in primary headache disorders have been known for a number of years.55 Researchers have found changes in the retino–hypothalamic–pituitary (RHP) system. Evidence for the RHP hypothesis, including recent PET studies showing

Parasomnias and headache

Parasomnias are undesirable physical events or experiences that occur during entry into sleep, within sleep, or during arousal from sleep.14 Exploding head syndrome is one of the more dramatic parasomnias.66 There is no pain, but the patient is awakened from sleep by a loud sound (and sometimes a flash of light).67 In a study of 222 children, Barabas et al. found a higher prevalence of sleepwalking in those with migraine compared to children with non-migrainous headaches, seizures, or learning

Sleep-related movement disorders and headache

Sleep-related movement disorders are primarily characterized by relatively simple, usually stereotyped, movements that disturb sleep or its onset.14 Restless legs syndrome (RLS) is a sensorimotor neurological disorder, affecting the limbs, mainly the lower extremities (Table 2).74 D׳Onofrio et al. found a higher prevalence of RLS in 200 patients with a number of primary headache compared to controls.75 A review by Schürks et al. of 24 studies by found a high prevalence of migraine in patients

Evaluation

The approach to the patient with sleep disorders follows usual medical evaluation involving chief complaint, current and past history (medical, neurological, and psychological), medications and allergies, family and social history, and review of systems. The focus is on how these contribute to the current sleep disorder(s).79 Chief complaints usually involve difficulty with sleep onset or maintenance, disturbance of sleep by movements or behaviors, sleep-disordered breathing, or daytime

Summary

Headaches and sleep disorders are associated in a complex manner. Both the disorders are common in the general population, but the relationship between the two is more than coincidental. Sleep disorders can exacerbate headaches and the converse is also true. Treatment of sleep disorders can have a positive impact on the treatment of headaches. Screening for sleep disorders should be considered in all patients with headaches. This can be accomplished with brief screening tools. Those who screen

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