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Sleep and Headache Handbook of Clinical Neurology, Vol. 99 (3rd series) Sleep Disorders, Part 2 P. Montagna and S. Chokroverty, Editors # 2011 Elsevier B.V. All rights reserved Chapter 63 Sleep and headache TERESA PAIVA* Institute of Molecular Medicine, Medical Faculty of Lisbon, Lisbon, Portugal INTRODUCTION functional links between sleep and headache, addres- sing the physiological, anatomic, chronobiological, Headache and sleep disturbances are commonly and genetic aspects as well as neurotransmitters and reported problems in neurological practice and both neuromodulators. have important individual and socioeconomic impacts. Their mutual relationships have been known for many years, but the full understanding of the underlying CLINICAL ASPECTS OF SLEEP^ mechanisms involved is still unclear. Basically, it is HEADACHE RELATIONS known that a headache may cause a sleep disturbance, Sleep and headache prevalence a sleep disturbance may be the cause of a headache, and both sleep and headache may be the consequence Headache patients more often report daytime symp- of another underlying condition (Paiva et al., 1995). toms (fatigue, tiredness, or sleepiness) and sleep pro- From clinical practice data it is clear that such a rela- blems (insomnia) (Paiva et al., 1995; Jennum and tion is complex, because a headache can be the result Jensen, 2002). In a specialized headache clinic, 17% of both too much and too little sleep, and can be both of the patients had awakening or nocturnal headache, cured by sleep and induced by it. This complexity must and 53% of them (9% of the total headache population) be considered in any scientific and clinical approach in had a sleep disorder (Paiva et al., 1997). order to achieve a deeper and clearer insight. A recent population study showed that poor sleep The recent publication of revised versions of the and anxiety have an important impact on the lives of International Classification of Headache Disorders headache sufferers. Those with moderate sleep pro- (ICHD-II) (Olesen, 2005) and International Classifica- blems had experienced significantly more headaches tion of Sleep Disorders (ICSD-2) (American Academy in the previous 3 months than controls (percentage of Sleep Medicine, 2005) implies an updated review occurrence 76% versus 24%; odds ratio 4.8), and the with some new concepts. In the ICHD-II, some sleep picture was still more impressive for severe sleep pro- entities are individualized, namely headache related to blems (percentage 87% versus 13% respectively; odds sleep apnea and hypnic headache, whereas in the ratio 13.0) (Boardman et al., 2005). ICSD-2 sleep-related headaches are referred to other The prevalence of chronic morning headache classifications in Appendix A. (CMH) is 7.6%, as determined in a European study The first section of this chapter describes clinical including a total of 1890 subjects from the UK, aspects of sleep–headache relations: sleep and head- Germany, Italy, Portugal, and Spain. CMH is more ache prevalence; clinical evaluation (parameters used common in females and in subjects between 45 and to characterize the mutual influences); sleep distur- 64 years of age. The most significant associated fac- bances coursing with headaches; headaches coursing tors are anxiety, depressive disorders, insomnia, dys- with sleep disturbances; sleep disturbances and head- somnia, and circadian rhythm disorder (Ohayon, ache as comorbid symptoms; and when to suspect a 2004). The picture is similar in young subjects: in the sleep disturbance in the evolution of a chronic head- USA, a national survey including 6072 adolescents ache, and vice versa. The second section deals with showed a clear relation between insomnia and headache *Correspondence to: Teresa Paiva, M.D., Ph.D., Centro do Sono, CENC, Rua Conde das Antas, 5, 1700 Lisboa, Portugal. Tel: 351213715450, Fax: 351213715459, E-mail: [email protected] 1074 T. PAIVA in less than 10% (Rhee, 2000). A Hong Kong cross- severity, triggers, associated and premonitory symp- sectional questionnaire survey of 3355 secondary toms, relieving and aggravating factors, and family school students (response rate 98%), attempting to history of headache. investigate common illnesses, found a similar preva- Several other clinical parameters must also be con- lence for headache and insomnia: headache/dizziness sidered in order to evaluate sleep–headache relations: (23.6%) and chronic anxiety/insomnia (20.1%) (Lau (1) sleep as a trigger for headaches; (2) headaches et al., 2000). related to the duration of sleep or changes in the sleep schedule; (3) sleep stage-related headaches; (4) associa- Clinical evaluation tion with a specific sleep pattern; (5) sleep as a head- ache reliever; (6) headaches and dreams; and (7) Headache evaluation should include at least a brief headaches affecting sleep. A summary is shown in sleep history (Rains and Poceta, 2005), and this should Table 63.1. also be applied to sleep patients who also need a head- ache evaluation. As well as conventional questions, the SLEEP-TRIGGERED HEADACHES sleep history should specifically address symptoms of sleep onset (sleep latency, limb discomfort or restless- Headaches are classified as sleep related when 75% ness, anxiety); nocturnal symptoms (snoring, nocturia, of the episodes occur during sleep or upon awaken- dreaming, abnormal behaviors), morning symptoms ing. Several of the currently known headache entities (dry mouth, headache, body pain, fatigue), and diurnal sometimes fulfil these requirements: migraine, cluster symptoms (sleepiness, performance difficulties, headache (CH), chronic paroxysmal hemicrania (CPH), fatigue, depression, pain). Headache history should hypnic headache, exploding head syndrome, and noc- consider type, location, frequency, time of occurrence, turnal hypertension headache. Table 63.1 Clinical evaluation of sleep and headaches Sleep history Sleep onset (sleep latency, limb restlessness, anxiety) Nocturnal symptoms (snoring, nicturia, dreaming, abnormal behaviors) Morning symptoms (dry mouth, headache, body pain, fatigue) Diurnal symptoms (sleepiness, performance difficulties, fatigue, depression, pain) Headache Type and location Frequency Time of occurrence (time of the day, relation to sleep and to awakening) Severity Associated and premonitory symptoms Triggers Relieving and aggravating factors Familiar cases Sleep–headache interactions Sleep as a trigger for headaches Migraine, CH, CPH, hypnic headache, exploding head syndrome Headaches related to the duration of sleep Migraine: excess, lack, scheduling of sleep or changes in sleep schedule Tension headache: lack of sleep Sleep phase-related headaches Most headaches occur in REM and NREM sleep, with higher probability for REM Exploding head syndrome and turtle headache in sleep–wake transitions Association with a specific sleep pattern Migraine: signs of lower cortical activation Tension headache: decreased sleep efficiency Sleep as a headache reliever Migraine Headaches and dreams Dreams culminating in a migraine Greater anger and apprehension Headaches affecting sleep CH, CPH, and hypnic headache may induce insomnia and awakenings CH, cluster headache; CPH, chronic paroxysmal hemicrania; NREM, nonrapid eye movement; REM, rapid eye movement. SLEEP AND HEADACHE 1075 SLEEP DURATION AND SLEEP SCHEDULE main trigger for CH attacks (Kudrow et al., 1984; Kudrow, 1994; Nobre et al., 2003). CPH has been con- Normal subjects, when sleep deprived, may experience sidered a REM-locked headache (Kayed et al., 1973), a dull or pressing bilateral headache in the forehead but polysomnographic studies have shown that the (Blau, 1990). Migraine attacks can be precipitated by trigger is not the sleep state but a sustained increase excessive sleep or lack of sleep (Sahota and Dexter, in blood pressure (Concili et al., 1994). 1990). A recent population study evaluating the preva- Hypnic headache occurrence across the night may lence of migraine and tension headache in Japan, by vary, but for the majority of patients (60% of 71 cases) means of structured questionnaires in adult residents the pain started 3 hours after falling asleep (Evers and of Daisen (n ¼ 5758; 4795 responders, 83.3% response Goadsby, 2003). A few patients have been recorded by rate) showed that “lack of sleep” triggered 51.6% of polysomnography during attacks; some had REM- cases of migraine with aura, 44.1% of migraine without related and others NREM-related headaches (Arjona aura, 32.0% of episodic tension headache, and 36.6% et al., 2000; Evers and Goadsby, 2003). In nocturnal of chronic tension headache; the “excess sleep” trigger headache hypertension syndrome, pain can appear in was significantly less common, being 3.3%, 8.9%, the morning hours. In exploding headache syndrome, 5.6%, and 1.4% respectively (Takeshima et al., 2004). attacks occur during the transition from wakefulness Migraineurs sleeping for fewer than 6 hours had to sleep, and in the turtle syndrome pain appears after more severe headaches and more sleep-related head- morning awakening when the patient pulls the sheet aches (Kelman and Rains, 2005). Lack of sleep is also over their head (Evers and Goadsby, 2003). a cause for tension headaches (Drake et al., 1990). Transient modification in sleep schedule (weekends, SLEEP PATTERN trips, etc.) by sleeping too little, too much, or by chang- ing routines can precipitate headaches (Spierings et al., A total of 164 children with migraine evaluated by 2001), particularly migraine (Olesen, 2005). A short nap questionnaire had longer sleep latency
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