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P1: KWW/KKL P2: KWW/HCN QC: KWW/FLX T1: KWW GRBT050-134 Olesen- 2057G GRBT050-Olesen-v6.cls August 17, 2005 2:18 ••Chapter 134 ◗ Headaches and Sleep Poul Jennum and Teresa Paiva Headache and sleeping problems are both some of the maintaining sleep), hypersomnias (with excessive day- most commonly reported problems in clinical practice and time sleepiness), parasomnias (disorders of arousal, par- cause considerable social and family problems, with im- tial arousal, and sleep stage transition), or circadian portant socioeconomic impacts. There is a clear associa- disturbances. tion between headache and sleep disturbances, especially Sleep is regulated by a complex set of mechanisms headaches occurring during the night or early morning. including the hypothalamus and brainstem and involv- The prevalence of chronic morning headache (CMH) is ing a large number of neurotransmitters including sero- 7.6%; CMH is more common in females and in subjects tonin, adenosine, histamine, hypocretin, γ -aminobutyric between 45 and 64 years of age; the most significant asso- acid (GABA), norepinephrine, and epinephrine (65). How- ciated factors are anxiety, depressive disorders, insomnia, ever, the specific roles in the relation between sleep and and dyssomnia (75). headache disorders are only partly known. However, the cause and effect of this relation are not clear. Patients with headache also report more daytime symptoms such as fatigue, tiredness, or sleepiness and COMMON HEADACHE TYPES sleep-related problems such as insomnia (77,52). Identi- AND THE RELATION TO SLEEP fication of sleep disorders in chronic headache patients is worthwhile because identification and treatment of sleep Commonly reported headache disorders that show rela- disorders among chronic headache patients may be fol- tion to sleep are migraine, tension-type headache, cluster lowed by improvement of the headache. headache, and the very rare so-called hypnic headache. Migraine FUNCTIONAL LINKS BETWEEN HEADACHE AND SLEEP Potential relations between migraine and sleep have been established in several studies (1,14,16,18,47,66,83). Sleep is organized with a recurrent alternation of two ba- Changes in the quality of sleep may occur up to 2 days sic sleep stages: REM (rapid eye movement) and NREM before a migraine attack (94,95). The sleep pattern may (no rapid eye movement) sleep, intermixed with small be involved in the precipitation of migraine attacks, but amounts of the awake state/arousals (Fig. 134-1). Sleep the reports are conflicting. Overuse of medication may serves a complex set of functions including tissue re- worsen the sleep pattern and headache. Withdrawal of the pair, anabolic hormones, thermoregulation, immune func- overused medication can alleviate the associated sleep dis- tion, and synaptic reorganization and has significant in- turbance along with the headache (41). fluence on cognitive function, including maintenance of Outside of migraine attacks, sleep pattern and elec- memory (58–60). Sleep deprivation or fragmentation in- tromyographic (EMG) activity are normal, although the duces sleepiness, fatigue and tiredness, headaches, anxiety, quantity of REM sleep and REM latencies were reported lack of concentration, confusion, perception disturbances, to be slightly increased in one study (30). Headaches and learning deficits, growth problems, increased health risks, migraine with aura may be related to extended sleep du- and accidents (10,11,21,42,56,85,86,96). Sleep disorders ration (68). Apart from these findings, there is no evidence may present as insomnias (with difficulties initiating or that sleep per se provokes migraine attacks. 1099 P1: KWW/KKL P2: KWW/HCN QC: KWW/FLX T1: KWW GRBT050-134 Olesen- 2057G GRBT050-Olesen-v6.cls August 17, 2005 2:18 1100 Special Problems in the Headaches and Their Management FIGURE 134-1. Sleep stages: REM, rapid eye movement sleep; NREM, non-REM; stage 2, light sleep; stage 4, deep sleep; LEOG, left electro-oculography; REOG, right electro-oculography; C3, left central electroencephalography (reference right mastoid); C4, right central electroencephalog- raphy; EMG, electromyography (submental). Note that the electroencephalographic mea- sures (K-complexes during NREM2 and δ waves during NREM4) are also presented in the EOG. Each trace represents 5 seconds. Tension-Type Headache of acute attacks, a potential relation between CH and sleep disordered breathing (SDB) has been hypothesized. Tension-type headache (TTH) is often associated with Sleep apnea has been found in a number of CH patients sleep disturbances such as insomnia, hypersomnia, and (24,34,62). Small case series suggest that continuous pos- circadian disturbances. Drake et al.(31) studied sleep elec- itive airway pressure (CPAP) treatment of sleep apnea in troencephalogram (EEG), electro-oculogram (EOG), and CH patients reduces CH severity (70,63). Sleep apnea prob- EMG with a four-channel cassette EEG recorder in 10 ably does not cause CH, but may worsen CH attacks. Tran- common (without aura) migraine patients, 10 individ- sient recurrent situational insomnia has been described in uals with muscle contraction (tension-type) headache, association with CH and diminished after the cluster pe- and 10 chronic tension–vascular headache sufferers (pre- riod subsided (88,89). A single case report has described International Headache Society [IHS] classification). Mi- episodic CH in a patient with narcolepsy, but a causal re- graine patients had essentially normal sleep, although lation is doubtful. Headache attacks are often related to REM sleep and REM latency were increased outside the at- REM sleep in episodic CH, but this relation is unclear in tacks. Patients with TTH had reduced sleep time and sleep chronic CH (80). efficiency, decreased sleep latency but frequent awaken- ings, increased nocturnal movements, and marked reduc- tion in slow wave sleep, without change in the amount of Hypnic Headache REM sleep. Mixed headaches with both tension and vas- Headache attacks occur predominantly during nocturnal cular features were also associated with reduced sleep, in- sleep, but may also occur during daytime naps. The mech- creased awakening, and diminished slow wave sleep. Fur- anism is not known, but casuistic reports have suggested thermore, REM sleep amount and latency were reduced. an association between arousal and headache episodes The findings suggest that patients with intermittent mi- during SWS (5), REM sleep, or nocturnal desaturations graine may have minimal sleep disturbance, while more (32,35,81). Alteration of unidentified biologic pacemakers chronic headache disorders may be associated with or has been suggested (78), whereas other studies have not worsened by poor sleep. The patient with TTH may have identified any clear relation to sleep stages, time of the frequent awakenings and decreased slow wave sleep. The night, or any external factors. Changes in arterial blood limitation of the study is that other causes of arousals and pressure prior to nocturnal headache have been reported fragmented sleep were not determined (i.e., sleep apnea in few subjects (26). Whether this may represent presence and periodic limb movements); furthermore, the headache of sleep apnea or changes in sympathetic outflow is not disorders were not properly classified and the use of anal- known. gesic drugs was not evaluated. There is still need for more studies of the relation between TTH and sleep. SLEEP DISORDERS AND THEIR Cluster Headache RELATION TO HEADACHE Cluster attacks may be provoked in the transition phase Insomnia from REM to non-REM sleep (23,33,61,69,74,79,101). Be- cause cluster headache (CH) occurs mainly during sleep Insomnia, defined by difficulties falling asleep and/or dif- and because oxygen supply is effective in the treatment ficulties maintaining sleep, is a very common complaint, P1: KWW/KKL P2: KWW/HCN QC: KWW/FLX T1: KWW GRBT050-134 Olesen- 2057G GRBT050-Olesen-v6.cls August 17, 2005 2:18 Headaches and Sleep 1101 ◗ TABLE 134-1 Most Frequent Differential and daytime headache, but the relation is weak (49,72,99). Diagnoses to Sleep-Related Headache may also be associated with sleepiness and ex- Headaches cessive daytime sleepiness (hypersomnia). Sleep apnea is Primary headaches mainly associated with TTH; the association to migraine Migraine is weak (50,53,84). A relation between sleep apnea and Cluster headache headache is most pronounced in the elderly. Tension-type headache The pathophysiologic background for a relation be- Hypnic headache tween sleep apnea and headache is multifactorial. Patients Secondary headaches due to: with sleep apnea suffer from repetitive nocturnal arousals Cerebral tumors due to the apnea, excessive daytime sleepiness, and cog- OSAS and other sleep-disordered breathing nitive complaints, factors that all may show relation to Restless legs syndrome and periodic leg movements headache. During apnea there are significant changes in Insomnia, sleep fragmentation, prolonged, and shortened sleep intracranial and cardiovascular hemodynamics, including Drugs intracranial pressure variations, changes in cerebral per- Alcohol fusion pressure, hypoxemia, and hypercapnia. In addition, Depression the repeated sleep-related arousals cause REM and NREM Mental stress or posttraumatic stress syndromes Neuromuscular disorders stage 3 and 4 suppression. These physiologic events result Cancer in increased sympathetic outflow, alterations in blood pres- Epilepsy sure control mechanisms, dysfunctional respiratory regu- Cardiovascular diseases lation,
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