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Primary Headaches and Their Relationship with Sleep Cefaleias Primárias E Sua Relação Com O Sono

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Primary Headaches and Their Relationship with Sleep Cefaleias Primárias E Sua Relação Com O Sono Yagihara F, Lucchesi LM‚ Smith AKA, Speciali JG 28 REVIEW ARTICLE Primary headaches and their relationship with sleep Cefaleias primárias e sua relação com o sono Fabiana Yagihara1, Ligia Mendonça Lucchesi1, Anna Karla Alves Smith1, José Geraldo Speciali2 ABSTRACT pain control systems. In general, pain affects sleep and vice There is a clear association between primary headaches and sleep versa(1,2). We found that primary headaches with no clear disorders, especially when these headaches occur at night or upon etiology by clinical and laboratory tests can be triggered by waking. The primary headaches most commonly related to sleep either short or long periods of sleep, or by interrupted or are: migraine, cluster headache, tension type, hypnic headache and (3) chronic paroxysmal hemicrania. The objective of this review was to non-restorative sleep . Sleep is also effective in relieving describe the relationship between these types of headaches and sle- symptoms: 85% of individuals with migraine report that ep and to address sleep apnea headaches. There are various types of they choose to sleep or rest because of a headache, and demonstrated associations between sleep and headache disorders, many are forced to do it(4). Therefore, headaches and sleep and the mechanisms underlying these associations are complex, multi-factorial and poorly understood. Moreover, all sleep disorders disturbances are common and often coexist in the same may be related to headaches to some degree; therefore, the evalua- individual(3,5), and this association is especially observed tion of patients with headaches should include a brief investigation when these headaches occur at night or upon waking(6,7). on sleep patterns and related complaints. Patients with headache at Sleep-related headaches and the relationship be- night or upon waking who are resistent to the indicated treatment require formal polysomnographic evaluation to exclude a treatable tween sleep and headaches are not well understood, but sleep disorder. recent advances in the neurophysiology of sleep suggest Keywords: headaches, migraine disorders, obstructive, pain, sleep that the biological processes behind this association lie in apnea, sleep disorders. neuroanatomical systems common to both(5,6). Anatomical, biochemical and physiological data support an inherent as- RESUMO sociation between normal sleep physiology and the gen- Uma clara associação é observada entre cefaleias primárias e distúr- esis of headaches in biologically predisposed individuals(3). bios do sono, especialmente quando estas cefaleias ocorrem duran- These data point to common pathophysiological aspects te a noite ou ao despertar. As cefaleias primárias mais relacionadas of sleep, pain (headache) and mood, which involve the ao sono são: migrânea ou enxaqueca, cefaleia em salvas, cefaléias hypothalamus, serotonin and melatonin(3). Preliminary do tipo tensional, cefaléia hípnica e hemicrania paroxística crôni- ca. O objetivo desta revisão foi mostrar a associação estes tipos de studies suggest that headaches tend to be associated with cefaleia e sono, abordando, também, a cefaleia da apneia do sono. rapid eye movement (REM) sleep and an increase in the Existem associações demonstradas e de diversos tipos entre o sono percentage of REM and slow wave sleep (SWS)(8). e transtornos de cefaleia e os mecanismos subjacentes a estas asso- Reviews of clinical and epidemiological studies ciações são complexos, multifatoriais e ainda mal compreendidos. suggest a higher prevalence of sleep disorders in indi- Além do mais, todos os distúrbios de sono podem ter relação com a cefaleia em maior ou menor grau e, por esta razão, a avaliação do viduals with certain types of headaches, such as migraine, (3,5,9) paciente com cefaleia deve incluir um breve questionamento sobre cluster headache and others . In addition, chronic daily o padrão ou queixas do sono deste. Pacientes com cefaleia notur- headache or headache on waking is strongly suggestive of na ou ao despertar, refratários aos tratamentos indicados requerem a sleep disorder. It is estimated that 4-6% of the general avaliação formal com polissonografia para exclusão de um distúr- population have a sleep disorder(10,11). Studies suggest that bio do sono tratável. of these individuals, approximately 18-60% are apneics Descritores: cefaleia, distúrbios do sono, dor, síndrome da apneia and 18% are insomniacs. Mitsikostas et al.(12) identified obstrutiva do sono, transtornos de enxaqueca. obstructive sleep apnea syndrome (OSAS) in 29% of pa- INTRODUCTION tients with severe headaches resistent to standard treat- ments. A relationship between sleep and headaches has been re- In a recent article, we examined the prevalence of ported in lay and scientific literature for over a century. nocturnal awakening with headache (NAH) in a popula- Regulation of the sleep-wake cycle is mediated by the in- tion in Sao Paulo, Brazil. The prevalence of NAH (at least teraction of different neural systems and their respective once a week) was 8.4% in the population studied. The neurotransmitters, components of which are shared with Study carried out at Departamento de Psicobiologia – Universidade Federal de São Paulo. 1 Departamento de Psicobiologia, Universidade Federal de São Paulo, Brasil. 2 Departamento de Neurociência e Ciências do Comportamento, Universidade de São Paulo, Campus Ribeirão Preto, Brasil. Corresponding author: Ligia Mendonça Lucchesi. Departamento de Psicobiologia – Universidade Federal de São Paulo/UNIFESP. Rua Napoleão de Barros, 925 - São Paulo (SP), Brazil - CEP 04024-002 - Phone: 55 (11) 21490155 - Fax: 55 (11) 55725092 - E-mail: [email protected] Submitted: April 16, 2011; Accepted: September 05, 2011. Sleep Sci. 2012;5(1):28-32 91 - Primary headaches and their relationship with sleep.indd 28 25/05/2012 18:57:47 29 Primary headaches and their relationship with sleep identified risk factors for NAH were: female, age of 50-59 mation, nasal congestion, rhinorrhea, forehead and facial years, obesity, anxiety, restless leg syndrome (RLS), insom- sweating, eyelid edema, miosis and ptosis. nia and nightmares(13). However, no assessment was made Sleep has long been linked to CH. Initial observa- of headache type according to International Classification tions indicated that patients frequently or always report of Headache Disorders, 2nd Edition (ICHD-II)(14). CH onset during sleep, with pain so unbearable that it jolts The objective of this review is to discuss the main the person awake(29). types of primary headache most often associated with The attacks usually occur approximately ninety sleep: migraine, cluster headache, tension type and hypnic minutes after the patient falls asleep, coincident with the headache and chronic paroxysmal hemicrania (CPH). As first episode of REM sleep. In fact, although data in the an exception to this proposal, we will discuss sleep apnea literature are controversial, these attacks tend to occur headache, which is the only diagnosis of headache second- mostly during REM sleep(3). The pain may also begin in ary to a sleep disorder formally recognized by ICHD-II(14). stages 2 and 3 of NREM sleep, and patients may experi- It is part of a subclassification of headaches related to hy- ence a reduction of REM sleep and an increase of SWS poxia, and one of its diagnostic criteria is that it can only during cluster headaches(30). The frequency of cluster be confirmed after successful treatment of sleep apnea. headaches is one or two times per year, demonstrating their circannual nature. Moreover, the influence of sleep PRIMARY HEADACHES RELATED TO SLEEP stages suggests hypothalamic involvement, in particular Migraine the suprachiasmatic nucleus, in the common pathophysi- Migraines are severe, usually unilateral headaches that ological processes of sleep and headache(19). commonly present symptoms such as photophobia, pho- Cluster headache patients have a high risk for nophobia, nausea, vomiting, mood disorders and sensory OSAS, as reported in various studies(12,30,31); polysomnog- abnormalities(15). They are closely related to sleep, and raphy (PSG) is necessary in patients with cluster head- migraines may occur during nocturnal sleep, after brief aches resistant to usual treatment(32-34). periods of daytime sleep and upon waking. In fact, ap- A case study monitoring a patient with cluster head- proximately 50% of migraine attacks occur between 4:00 aches over a 9-week actigraphy recording and repeated a.m. and 9:00 a.m.(3). In addition, sleep problems are 3 PSG showed acute sleep-wake pattern changes and REM times more frequent among patients who reported having sleep abnormalities, both of which diminished after the migraines(16). The migraine crisis can be triggered by lack episode(35). The authors concluded that in this patient, the of sleep or sleeping too much; however, it often improves CH was associated with poor regulation of the sleep-wake or disappears after sleep(17). These crises are not associ- cycle, involving the biological clock and alertness mecha- ated with a particular sleep stage: they may occur during nisms, particularly in REM sleep; all of these abnormali- REM sleep or outside this period; they are more likely to ties were consistent with alteration of the posterior hypo- occur after long periods of SWS stage and/or upon wak- thalamus(35). Studies using positron emission tomography ing from REM sleep, when the patient is dreaming and support this conclusion(36). Moreover, the efficacy of lith- has a headache(3,18). The cyclical or periodic nature of the ium treatment has been shown to involve the hypothala- attacks and their relationship with cycles (sleep, menstrua- mus, resulting in selective accumulation and stabilization tion, season of the year) and sunny days indicate circadian of serotonin in the central nervous system, causing inhibi- mechanisms controlled by the hypothalamus(19). tion of REM sleep and circadian rhythm changes(3). Insomnia is among the sleep disorders most com- monly related to migraine and is present in one half to two Tension-type headaches thirds of the migraine sufferers(16,17,20). The incidence of Tension-type headaches can be episodic or chronic.
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