Disease-a-Month 61 (2015) 240–248
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Headaches and sleep disorders Thomas Freedom, MD
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.
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 http://dx.doi.org/10.1016/j.disamonth.2015.03.008 0011-5029/& 2015 Mosby, Inc. All rights reserved.
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The latest classification of sleep disorders, International Classification of Sleep Disorders, third edition (ICSD-III) refines the previous edition and adds compatibility with ICD-10. The International Classification of Sleep disorders, third edition lists 59 sleep disorders in 6 categories, isolated symptoms and normal variants, and a category of Other Sleep Disorder (Table 1).14
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 migraine.17 There are a number of shared anatomical sites in the brainstem and the hypothalamus that are active in migraine and sleep.18,19 A number of studies have looked at the relationship between sleep and headache. Paiva et al.20 reported 49 patients with nocturnal headaches and found 26 to have sleep disorders. Odegard et al. evaluated the association between sleep disturbance and headache type and frequency in a random sample of patients. Among 297 participants, 77 subjects were without headache, 135 were diagnosed with tension-type headache (TTH), 51 had migraine, and 34 had other headache diagnoses. Excessive daytime sleepiness was 3 times as likely among migraineurs compared with headache-free individuals. Severe sleep disturbance was 5 times more likely among migraineurs and 3 times more likely for subjects with TTH compared with headache-free individuals. Those who had chronic headache were 17 times more likely to have severe sleep disturbance. There was a stronger association for chronic migraine vs. chronic TTH.21 Sancisi et al. found that 105 patients with chronic headache had a high prevalence of insomnia, daytime sleepiness, and snoring in addition to psychiatric comorbidity (anxiety and/or depressive disorders). Low educational level, lower mean age at headache onset, and insomnia are independently associated with chronic headache.22 However, a study by Vgontzas et al.23 of 221 patients and 226 relatives showed that headache persists in migraine even when controlling for anxiety and other mood disorders. Bruni et al.24 found a high co-occurrence of headaches and sleep problems in 893 child and adolescents by using questionnaires. Hypnic headaches were first described in 1988. They lead to awakening from sleep, which occurs at the same time for at least 15 days of the month.25 They are generally short lasting, bilateral, and do not have migrainous or autonomic features. They are rare below the age of 50 years.26 They respond to caffeine for both acute and preventive treatment. Sleep problems due to caffeine seem to occur far less than expected. Analgesics-containing caffeine can also be effective, but they may carry the risk of medication-overuse headache. Ineffective ones include nonsteroidal anti-inflammatory drugs, opioids, 100% oxygen, and acetaminophen. Triptans may be effective in single cases. Lithium has been reported to be effective in many patients, but it is often poorly tolerated. Indomethacin may be an option in prophylactic therapy.27
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, comorbid, or severe headache, the ORs ranged from 2.0 to 2.6.28 Lovati et al.29 found a strong correlation between the presence/absence of allodynia and sleep quality in 175 consecutive migraineurs (with and without aura). Alstadhaug et al.30 found that morning
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Table 1 International classification of sleep disorders-III. Adapted from Sateia (Ed).14 Insomnia disorders Chronic insomnia disorder Short-term insomnia disorder Other insomnia disorder Isolated symptoms and normal variants Excessive time in bed Short sleeper Sleep-related breathing disorders Obstructive sleep apnea disorders Obstructive sleep apnea, adult Obstructive sleep apnea, pediatric Central sleep apnea syndromes Central sleep apnea with Cheyne–Stokes breathing Central apnea due to a medical disorder without Cheyne–Stokes breathing Central sleep apnea due to high altitude periodic breathing Central sleep apnea due to a medication or substance Primary central sleep apnea Primary central sleep apnea of infancy Primary central sleep apnea of prematurity Treatment-emergent central sleep apnea Sleep-related hypoventilation disorders Obesity hypoventilation syndrome Congenital central alveolar hypoventilation syndrome Late-onset central hypoventilation with hypothalamic dysfunction Idiopathic central alveolar hypoventilation Sleep-related hypoventilation due to a medication or substance Sleep-related hypoventilation due to a medical disorder Sleep-related hypoxemia disorder Sleep-related hypoxemia Isolated symptoms and normal variants Snoring Catathrenia Central disorders of hypersomnolence Disorders Narcolepsy type 1 Narcolepsy type 2 Idiopathic hypersomnia Kleine–Levin syndrome Hypersomnia due to a medical disorder Hypersomnia due to a medication or substance Hypersomnia associated with a psychiatric disorder Insufficient sleep syndrome Isolated symptoms and normal variants Long sleeper Circadian rhythm sleep–wake disorders Disorders Delayed sleep–wake phase disorder Advanced sleep–wake phase disorder Irregular sleep–wake rhythm disorder Non-24-h sleep–wake rhythm disorder Shift work disorder Jet lag disorder Circadian sleep–wake disorder not otherwise specified (NOS) Parasomnias NREM-related parasomnias Disorders of arousal (from NREM sleep) Confusional arousals Sleepwalking Sleep terrors
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Table 1 (continued ) Sleep-related eating disorder REM-related parasomnias REM sleep behavior disorder Recurrent isolated sleep paralysis Nightmare disorder Other parasomnias Exploding head syndrome Sleep-related hallucinations Sleep enuresis Parasomnia due to a medical disorder Parasomnia due to a medication or substance Parasomnia, unspecified Isolated symptoms and normal variants Sleep talking Sleep-related movement disorders Disorders Restless legs syndrome Periodic limb movement disorder Sleep-related leg cramps Sleep-related bruxism Sleep-related rhythmic movement disorder Benign sleep myoclonus of infancy Propriospinal myoclonus at sleep onset Sleep-related movement disorder due to a medical disorder Sleep-related movement disorder due to a medication or substance Sleep-related movement disorder, unspecified Isolated symptoms and normal variants Excessive fragmentary myoclonus Hypnagogic foot tremor and alternating leg muscle activation Sleep starts (Hypnic Jerks) Other sleep disorder
migraine was associated with insomnia in 68 female patients. Calhoun et al.31 studied 177 females with transformed migraine (TM) and reported that nonrestorative sleep was a prevalent comorbid condition in women with TM. Behavioral therapy for insomnia may cause TM to revert back to episodic migraine.32
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.33–35 Habitual snoring was also associated with morning headache in a study of 268 patients done by Chen et al.36 Bed partners of habitual snorers were also found to have a higher prevalence of morning headaches.37 Scher et al.38 found increase snoring in 2757 patients with chronic daily headache. A higher prevalence of obstructive sleep apnea has been noted in cluster headache in a number of case reports.39–42 Increase in central apnea was demonstrated by Evers et al.43 in patients with active cluster headaches. Treatment with positive airway pressure was associated with improvement in cluster headache in most44–46 but not all43 studies. On the other hand, other studies have not shown a relationship between sleep-disordered breathing and morning headaches.47,10 However, a study showing no difference in severity of obstructive sleep apnea in patients with or without migraine found an improvement in headaches in patients who were treated with positive airway pressure.48 In a cross-sectional
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population-based study of 4000 patients utilizing questionnaires, Kristiansen et al. did not find an increased prevalence in migraine with or without aura and obstructive sleep apnea. There was also no relationship to sleep apnea severity.49 Prevalence of tension-type headache was also not increased compared to controls.50
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 frequency of headaches in patients with narcolepsy, but there are conflicting data regarding the increase in migraine frequency.53,54
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 changes in dorsal pons, hypothalamus, and rostral limbic structures; acute, periodic, or chronic circadian desynchrony; and dysfunction of the whole or part of the RHP axis, supports involvement in the pathophysiology of primary headaches.56 The occurrence of cluster headaches at fixed times every day during an episode is well known.57 Alteration of circadian secretion of melatonin and cortisol has been found.58 There is a circadian pattern to the timing of migraine attacks.59 Hypnic headache occurs at a fixed time after sleep onset.60 Melatonin may be effective in different headache types, including cluster61,62 and hypnic headaches.63 There are conflicting studies in migraine.64,65 Some of these studies support a circadian involvement in primary headaches.
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 disability.68 Characteristic dream patterns were described in 22 patients with migraines by Lippman.69 Dreams preceding migraine have mainly negative content as reported by Levitan70 and by Heather-Greene et al.71 Dream-enactment behavior had a higher prevalence in 161 migraine patients with impaired sleep and severe headache-related disability in patients as reported by Suzuki et al.72 Elementary visual geometric patterns resembling migraine auras were incorporated into dreams preceding migraines.73
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
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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 with RLS and high prevalence of migraine in RLS patients.76 Cologno et al. found that the chances of having RLS in migraine patients were more than 5 times higher in the presence of dopaminergic premonitory symptoms.77 Bruxism can be associated with headaches.78
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 sleepiness. The history is focused on determining these factors. A history of sleep and wake habits and factors that can contribute to disruption of sleep (e.g., caffeine, tobacco, and alcohol) are important.80 The sleep environment is another factor that should be assessed. The comfort of the bed, disruption of sleep from noise, temperature, children, pets, and bed partner are the important factors. Television, radio, or computers in the bedroom may also be distractions to sleep and their presence should be ascertained.79,80 Physical examination includes general and neurological assessment. In sleep-disordered breathing, the focus should be on the upper airway and neck.79 More extensive neurological evaluation is important in sleep-related movement disorders, parasomnias, and hypersomnias. Questionnaires and sleep logs can be useful. There are numerous validated scales used in sleep medicine that may be used for screening.81 Many are focused on particular areas such as insomnia,82 sleep apnea,83,84 or restless legs syndrome.74 The Pittsburgh Sleep Quality Index is a validated instrument that assesses sleep quality and disturbances over the previous month.85 The Functional Outcomes of Sleep Questionnaire is used to evaluate the impact of sleepiness on activities of daily living.86 The Epworth Sleepiness Scale (ESS) consists of questions assessing sleepiness. There are 8 daytime situations in which it is asked what are the chances of dozing.87 The Stanford Sleepiness Scale is a self-rating of sleepiness at the time asked. There are 7 choices ranging from full alertness to inability to stay awake.88 These scales are helpful in both clinical evaluation and response to therapy. Nocturnal Polysomnography is used in the sleep laboratory to evaluate sleep disorders. It is normally indicated for diagnosing sleep-related breathing disorders, to administer positive airway pressure, for evaluating narcolepsy and other hypersomnias, and to assess unusual or atypical parasomnias-especially when violent or injurious behaviors occur during sleep. It is not Table 2 International restless legs study group diagnostic criteria. Adapted from International restless legs syndrome study group.74 1. An urge to move the legs usually but not always accompanied by or felt to be caused by uncomfortable and unpleasant sensations in the legs. 2. The urge to move the legs and any accompanying unpleasant sensations begin or worsen during periods of rest or inactivity such as lying down or sitting. 3. The urge to move the legs and any accompanying unpleasant sensations are partially or totally relieved by movement, such as walking or stretching, at least as long as the activity continues. 4. The urge to move the legs and any accompanying unpleasant sensations during rest or inactivity only occur or are worse in the evening or night than during the day. 5. The occurrence of the above features is not solely accounted for as symptoms primary to another medical or a behavioral condition (e.g., myalgia, venous stasis, leg edema, arthritis, leg cramps, positional discomfort, and habitual foot tapping.)55
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indicated in chronic lung disease, typical or noninjurious parasomnias, seizures without sleep disturbance, restless legs, circadian rhythm disorders, insomnia, or to diagnose depression.89 Physical measurements include electroencephalography, electrooculography, chin electromyography, airflow, nasal pressure, respiratory effort, arterial oxygen saturation, electrocardiography, and electromyography of the lower extremities.90 Portable sleep studies can be done in the home, mainly to diagnose sleep apnea in patients who screen positively for sleep apnea and have no other underlying sleep disorders or severe cardiac pulmonary disease.91 Actigraphy allows for longer evaluation of sleep–wake cycles. It may be useful for insomnia and circadian rhythm disorders.92 The device is a small motion detector worn on the wrist usually for 1–2 weeks.93 A quick screening tool from the pediatric literature uses a pneumonic BEARS. It consists of asking about bedtimes, excessive daytime sleepiness, arousals, duration of sleep, regularity of sleep, and snoring.94 This may be useful for adult patients but has not been validated.
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 positively can be further evaluated or referred to a sleep specialist. References 1. Alberti A. Headache and sleep. Sleep Med Rev. 2006;10(6):431–437. http://dx.doi.org/10.1016/j.smrv.2006.03.003. 2. Victor TW, Hu X, Campbell JC, Buse DC, Lipton RB. Migraine prevalence by age and sex in the United States: a lifespan study. Cephalalgia. 2010;30(9):1065–1072. 3. Westergaard ML, Glümer C, Hansen EH, Jensen RH. Prevalence of chronic headache with and without medication overuse: associations with socioeconomic position and physical and mental health status. Pain. 2014;155(10): 2005–2013. 4. Jennum P, Riha RL. Epidemiology of sleep apnoea/hypopnoea syndrome and sleep-disordered breathing. Eur Respir J. 2009;33(4):907–914. 5. Koo BB. Restless legs syndrome: relationship between prevalence and latitude. Sleep Breath. 2012;16(4):1237–1245. 6. Richey SM, Krystal AD. Pharmacological advances in the treatment of insomnia. Curr Pharm Des. 2011;17(15): 1471–1475. 7. Roth T. Prevalence, associated risks, and treatment patterns of insomnia. J Clin Psychiatry. 2005;66(suppl 9):10–13. 8. Singh NN, Sahota P. Sleep-related headache and its management. Curr Treat Options Neurol. 2013;15(6):704–722. 9. Rains JC, Poceta JS, Penzien DB. Sleep and headaches. Curr Neurol Neurosci Rep. 2008;8(2):167–175. 10. Aldrich MS, Chauncey J. Are morning headaches part of obstructive sleep apnea syndrome?. Arch Intern Med. 1990;150:1265–1267. 11. Evans RW, Dodick DW, Schwedt TJ. The headaches that awaken us. Headache. 2006;46(4):678–681. 12. Cortelli P, Pierangeli G. Hypothalamus and headaches. Neurol Sci. 2007;28(suppl 2):S198–S202. 13. Sateia M, ed. International Classification of Sleep Disorders: Diagnostic and coding manual. 2nd ed. Westchester, IL: American Academy of Sleep Medicine; 2005. 14. Sateia M, editor. International Classification of Sleep Disorders. 3rd ed. Darien: American Academy of Sleep Medicine; 2014. 15. Aguggia M, Cavallini M, Divito N, et al. Sleep and primary headaches. Neurol Sci. 2011;32(suppl 1):S51–S54. 16. Rains JC, Poceta JS. Sleep and headache disorders: clinical recommendations for headache management. Headache. 2006;46(suppl 3):S147–S148. 17. Inamorato E, Minatti-Hannuch SN, Zukerman E. The role of sleep in migraine attacks. Arq Neuropsiquiatr. 1993;51(4): 429–432. 18. Evers S. Sleep and headache: the biological basis. Headache. 2010;50(7):1246–1251. 19. Dodick DW, Eross EJ, Parish JM, Silber M. Clinical, Anatomical, and physiologic relationship between sleep and headache. Headache. 2002;43(3):282–292. 20. Paiva T, Batista A, Martins P, Martins A. The relationship between headaches and sleep disturbances. Headache. 1995;35(10):590–596. 21. Odegard SS, Engstrom M, Sand T, et al. Associations between sleep disturbance and primary headaches: the third Nord-Trøndelag Health Study. J Headache Pain. 2010;11(3):197–206.
T. Freedom / Disease-a-Month 61 (2015) 240–248
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22. Sancisi E, Cevoli S, Vignatelli L, et al. Increased prevalence of sleep disorders in chronic headache: a case–control study. Headache. 2010;50(9):1464–1472. 23. Vgontzas A, Cui L, Merikangas KR. Are sleep difficulties associated with migraine attributable to anxiety and depression? Headache. 2008;48(10):1451–1459. 24. Bruni O, Fabrizi P, Ottaviano S, et al. Prevalence of sleep disorders in children and adolescents with headache: a case control study. Cephalalgia. 1997;17(4):492–498. 25. Raskin NH. The hypnic headache syndrome. Headache. 1988;28(8):534–536. 26. Liang J-F, Wang S-J. Hypnic headache: a review of clinical features, therapeutic options and outcomes. Cephalalgia. 2014;34(10):795–805. 27. Diener H-CC, Obermann M, Holle D. Hypnic headache: clinical course and treatment. Curr Treat Options Neurol. 2012;14(1):15–26. 28. Uhlig BL, Engstrøm M, Ødegård SS, Hagen KK, Sand T. Headache and insomnia in population-based epidemiological studies. Cephalalgia. 2014;34(10):745–751. 29. Lovati C, D’Amico D, Bertora P, et al. Correlation between presence of allodynia and sleep quality in migraineurs. Neurol Sci. 2010;31(suppl 1):S155–S158. 30. Alstadhaug K, Salvesen R, Bekkelund S. Insomnia and circadian variation of attacks in episodic migraine. Headache. 2007;47(8):1184–1188. 31. Calhoun AH, Ford S, Finkel AG, Kahn Ka, Mann JD. The prevalence and spectrum of sleep problems in women with transformed migraine. Headache. 2006;46(4):604–610. 32. Calhoun AH, Ford S. Behavioral sleep modification may revert transformed migraine to episodic migraine. Headache. 2007;47(8):1178–1183. 33. Poceta JS, Dalessio DJ. Identification and treatment of sleep apnea in patients with chronic headache. Headache. 1995;35(10):586–589. 34. Loh NK, Dinner DS, Foldvary N, Skobieranda F, Yew WW. Do patients with obstructive sleep apnea wake up with headaches? Arch Intern Med. 1999;159(15):1765–1768. 35. Neau JP, Paquereau J, Bailbe M, Meurice JC, Ingrand P, Gil R. Relationship between sleep apnoea syndrome, snoring and headaches. Cephalalgia. 2002;22(5):333–339. 36. Chen P-K, Fuh J-L, Lane H-Y, Chiu P-Y, Tien H-C, Wang S-J. Morning headache in habitual snorers: frequency, characteristics, predictors and impacts. Cephalalgia. 2011;31(7):829–836. 37. Seidel S, Frantal S, Oberhofer P, et al. Morning headaches in snorers and their bed partners: a prospective diary study. Cephalalgia. 2012;32(12):888–895. 38. Scher AI, Lipton RB, Stewart WF. Habitual snoring as a risk factor for chronic daily headache. Neurology. 2003;60(8): 1366–1368. 39. Kudrow L, McGinty DJ, Phillips ER, et al. Sleep apnea in cluster headache. Cephalalgia. 1984;4(1):33–38. 40. Chervin RD, Zallek SN, Lin X, Hall JM, Sharma N, Hedger KM. Sleep disordered breathing in patients with cluster headache. Neurology. 2000;54(12):2302–2306. 41. Nobre ME, Filho PFM, Dominici M. Cluster headache associated with sleep apnoea. Cephalalgia. 2003;23(4):276–279. 42. Graff-Radford SB, Newman A. Obstructive sleep apnea and cluster headache. Headache. 2004;44(6):607–610. 43. Evers S, Barth B, Frese A, Husstedt I-W, Happe S. Sleep apnea in patients with cluster headache: a case–control study. Cephalalgia. 2014;34(10):828–832. 44. Buckle P, Kerr P, Kryger M. Nocturnal cluster headache associated with sleep apnea. A case report. Sleep. 1993;16(5): 487–489. 45. Zallek SN, Chervin RD. Improvement in cluster headache after treatment for obstructive sleep apnea. Sleep Med. 2000;1(2):135–138. 46. Ludemann P, Frese A, Happe S, Evers S, Lu P. Sleep disordered breathing in patients with cluster headache. Neurology. 2001;56(7):984. 47. Jensen R, Olsborg C, Salvesen R, Torbergsen T, Bekkelund SI. Is obstructive sleep apnea syndrome associated with headache? Acta Neurol Scand. 2004;109(3):180–184. 48. Kallweit U, Hidalgo H, Uhl V, Sándor PS. Continuous positive airway pressure therapy is effective for migraines in sleep apnea syndrome. Neurology. 2011;76(13):1189–1191. 49. Kristiansen HA, Kværner KJ, Akre H, Overland B, Russell MB, Kvaerner KJ. Migraine and sleep apnea in the general population. J Headache Pain. 2011;12(1):55–61. 50. Kristiansen HA, Kvaerner KJ, Akre H, Overland B, Russell MB, Kværner KJ. Tension-type headache and sleep apnea in the general population. J Headache Pain. 2011;12(1):63–69. 51. Barbanti P, Fabbrini G, Aurilia C, Vanacore N, Cruccu G. A case–control study on excessive daytime sleepiness in episodic migraine. Cephalalgia. 2007;27(10):1115–1119. 52. Barbanti P, Aurilia C, Egeo G, Fofi L, Vanacore N. A case–control study on excessive daytime sleepiness in chronic migraine. Sleep Med. 2013;14(3):278–281. 53. Dahmen N, Kasten M, Wieczorek S, Gencik M, Epplen JT, Ullrich B. Increased frequency of migraine in narcoleptic patients: a confirmatory study. Cephalalgia. 2003;23(1):14–19. 54. The DMKG Study Group. Migraine and idiopathic narcolepsy—a case-control study. Cephalalgia 2003;23(8):786–9. 55. Ferrari E, Canepari C, Bossolo PA, et al. Changes of biological rhythms in primary headache syndromes. Cephalalgia. 1963;3(suppl 1):58–68. 56. Deshmukh VD. Retino–hypothalamic–pineal hypothesis in the pathophysiology of primary headaches. Med Hypotheses. 2006;66(6):1146–1151. 57. Waldenlind E. Physiological rhythms in cluster headache. Ital J Neruo Sci. 1999;20(suppl 2):s15–s17. 58. Pringsheim T. Cluster headache: evidence for a disorder of circadian rhythm and hypothalamic function. Can J Neurol Sci. 2002;29(1):33–40. 59. Fox AW, Davis RL. Migraine chronobiology. Headache. 1998;38(6):436–441.
248
T. Freedom / Disease-a-Month 61 (2015) 240–248
60. Dodick DW, Mosek AC, Campbell JK. The hypnic (“alarm clock”) headache syndrome. Cephalalgia. 1998;18(3): 152–156. 61. Peres M, Rozen T. Melatonin in the preventive treatment of chronic cluster headache. Cephalalgia. 2001;21(10): 993–995. 62. Leone M, Damico D, Moschiano F, Fraschini F, Bussone G. Melatonin versus placebo in the prophylaxis of cluster headache: a double-blind pilot study with parallel groups. 1996;11:0–2. 63. Dodick DW. Polysomnography in hypnic headache syndrome. Headache. 2000;40(9):748–752. 64. Peres MFP, Zukerman E, da Cunha Tanuri F, Moreira FR, Cipolla-Neto J. Melatonin, 3 mg, is effective for migraine prevention. Neurology. 2004;63(4):757. 65. Alstadhaug KB, Odeh F, Salvesen R, Bekkelund SI. Prophylaxis of migraine with melatonin: a randomized controlled trial. Neurology. 2010;75(17):1527–1532. 66. Frese A, Summ O, Evers S. Exploding head syndrome: six new cases and review of the literature. Cephalalgia. 2014;34 (10):823–827. 67. Green MW. The exploding head syndrome. Curr Pain Headache Rep. 2001;5(3):279–280. 68. Barabas G, Ferrari M, Matthews WS. Childhood migraine and somnambulism. Neurology. 1983;33(7):948–949. 69. Lippman CW. Recurrent dreams in migraine: an aid to diagnosis. J Nerv Ment Dis. 1954;120(3–4):273–276. 70. Levitan H. Dreams which culminate in migraine headaches. Psychother Psychosom. 1984;41(4):161–166. 71. Heather-Greener GQ, Comstock D, Joyce R. An investigation of the manifest dream content associated with migraine headaches: a study of the dreams that precede nocturnal migraines. Psychother Psychosom. 1996;65(4):216–221. 72. Suzuki K, Miyamoto T, Miyamoto M, et al. Dream-enacting behaviour is associated with impaired sleep and severe headache-related disability in migraine patients. Cephalalgia. 2013;33(10):868–878. 73. Podoll K, Töpper R, Robinson D, Sass H. Recurrent dreams as migraine aura symptoms. Fortschr Neurol Psychiatr. 2000;68(4):145–149. 74. International Restless Legs Syndrome Study Group. 2012 revised international Restless Legs Syndrome Study Group diagnostic criteria. Available at: 〈http://irlssg.org/diagnostic-criteria/〉; 2012. 75. d’Onofrio F, Bussone G, Cologno D, et al. Restless legs syndrome and primary headaches: a clinical study. Neurol Sci. 2008;29(suppl 1):S169–S172. 76. Schürks M, Winter A, Berger K, Kurth T. Migraine and restless legs syndrome: a systematic review. Cephalalgia. 2014;34(10):777–794. 77. Cologno D, Cicarelli G, Petretta V, D’Onofrio F, Bussone G. High prevalence of Dopaminergic Premonitory Symptoms in migraine patients with Restless Legs Syndrome: a pathogenetic link. Neurol Sci. 2008;29(Suppl 1):S166–188. 78. Lucchesi LM, Speciali JG, Santos-Silva R, Taddei JA, Tufik S, Bittencourt LRA. Nocturnal awakening with headache and its relationship with sleep disorders in a population-based sample of adult inhabitants of Sao Paulo City, Brazil. Cephalalgia. 2010;30(12):1477–1485. 79. Mallow B. Approach to the patient with disordered sleep. In: Kryger MH, Roth T, DW, eds. Principles and Practice of Sleep Medicine. 5th ed. St. Louis: Elsevier; 2011:641–646. 80. Chokroverty S. Approach to the patient with sleep complaints. In: Chokroverty S, ed. Sleep Disorders Medicine:Basic Scinece, GTechnical Considertions, and Clinical Aspects. 2nd ed. Boston: Butterworth-Heinemann; 1999:275–285. 81. Senthilvel E, Auckley D, Dasarathy J. Evaluation of sleep disorders in the primary care setting: history taking compared to questionnaires. J Clin Sleep Med. 2011;7(1):41–48. 82. Smith S, Trinder J. Detecting insomnia: comparison of four self-report measures of sleep in a young adult population. J Sleep Res. 2001;10(3):229–235. 83. Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med. 1999;131(7):535–536. 84. Chung F, Yegneswaran B, Liao P, et al. STOP Questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108(5):812–821. 85. Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193–213. 86. Chasens ER, Ratcliffe SJ, Weaver TE. Development of the FOSQ-10: a short version of the functional outcomes of sleep questionnaire. Sleep. 2009;32(7):915–919. 87. Johns MW. A new method for measuting daytime sleepiness: the Epworth Sleepiness Scale. Sleep. 1991;14(6): 540–545. 88. Hoddes EV. Methodology quantification of sleepiness: a new approach. Psychphysiology. 1973;10:431–436. 89. Owens Ja, Dalzell V. Use of the “BEARS” sleep screening tool in a pediatric residents' continuity clinic: a pilot study. Sleep Med. 2005;6(1):63–69. 90. Kushida Ca, Littner MR, Morgenthaler T, et al. Practice parameters for the indications for polysomnography and related procedures: an update for 2005. Sleep. 2005;28(4):499–521. 91. Jafari B, Mohsenin V. Polysomnography. Clin Chest Med. 2010;31(2):287–297. 92. Portable Monitoring Task Force of the American Academy of Sleep Medicine. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. J Clin Sleep Med. 2007;3 (7):737–747. 93. Morgenthaler T, Alessi C, Friedman L, et al. Practice parameters for the use of actigraphy in the assessment of sleep and sleep disorders: an update for 2007. Sleep. 2007;30(4):519–529. 94. Webster JB, Kripke DF, Messin S, Mullaney DJ, Wyborney G. An activity-based sleep monitor system for ambulatory use. Sleep. 1982;5(4):389–399.
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Headaches and sleep disorders Thomas Freedom, MD
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.
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 http://dx.doi.org/10.1016/j.disamonth.2015.03.008 0011-5029/& 2015 Mosby, Inc. All rights reserved.
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The latest classification of sleep disorders, International Classification of Sleep Disorders, third edition (ICSD-III) refines the previous edition and adds compatibility with ICD-10. The International Classification of Sleep disorders, third edition lists 59 sleep disorders in 6 categories, isolated symptoms and normal variants, and a category of Other Sleep Disorder (Table 1).14
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 migraine.17 There are a number of shared anatomical sites in the brainstem and the hypothalamus that are active in migraine and sleep.18,19 A number of studies have looked at the relationship between sleep and headache. Paiva et al.20 reported 49 patients with nocturnal headaches and found 26 to have sleep disorders. Odegard et al. evaluated the association between sleep disturbance and headache type and frequency in a random sample of patients. Among 297 participants, 77 subjects were without headache, 135 were diagnosed with tension-type headache (TTH), 51 had migraine, and 34 had other headache diagnoses. Excessive daytime sleepiness was 3 times as likely among migraineurs compared with headache-free individuals. Severe sleep disturbance was 5 times more likely among migraineurs and 3 times more likely for subjects with TTH compared with headache-free individuals. Those who had chronic headache were 17 times more likely to have severe sleep disturbance. There was a stronger association for chronic migraine vs. chronic TTH.21 Sancisi et al. found that 105 patients with chronic headache had a high prevalence of insomnia, daytime sleepiness, and snoring in addition to psychiatric comorbidity (anxiety and/or depressive disorders). Low educational level, lower mean age at headache onset, and insomnia are independently associated with chronic headache.22 However, a study by Vgontzas et al.23 of 221 patients and 226 relatives showed that headache persists in migraine even when controlling for anxiety and other mood disorders. Bruni et al.24 found a high co-occurrence of headaches and sleep problems in 893 child and adolescents by using questionnaires. Hypnic headaches were first described in 1988. They lead to awakening from sleep, which occurs at the same time for at least 15 days of the month.25 They are generally short lasting, bilateral, and do not have migrainous or autonomic features. They are rare below the age of 50 years.26 They respond to caffeine for both acute and preventive treatment. Sleep problems due to caffeine seem to occur far less than expected. Analgesics-containing caffeine can also be effective, but they may carry the risk of medication-overuse headache. Ineffective ones include nonsteroidal anti-inflammatory drugs, opioids, 100% oxygen, and acetaminophen. Triptans may be effective in single cases. Lithium has been reported to be effective in many patients, but it is often poorly tolerated. Indomethacin may be an option in prophylactic therapy.27
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, comorbid, or severe headache, the ORs ranged from 2.0 to 2.6.28 Lovati et al.29 found a strong correlation between the presence/absence of allodynia and sleep quality in 175 consecutive migraineurs (with and without aura). Alstadhaug et al.30 found that morning
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Table 1 International classification of sleep disorders-III. Adapted from Sateia (Ed).14 Insomnia disorders Chronic insomnia disorder Short-term insomnia disorder Other insomnia disorder Isolated symptoms and normal variants Excessive time in bed Short sleeper Sleep-related breathing disorders Obstructive sleep apnea disorders Obstructive sleep apnea, adult Obstructive sleep apnea, pediatric Central sleep apnea syndromes Central sleep apnea with Cheyne–Stokes breathing Central apnea due to a medical disorder without Cheyne–Stokes breathing Central sleep apnea due to high altitude periodic breathing Central sleep apnea due to a medication or substance Primary central sleep apnea Primary central sleep apnea of infancy Primary central sleep apnea of prematurity Treatment-emergent central sleep apnea Sleep-related hypoventilation disorders Obesity hypoventilation syndrome Congenital central alveolar hypoventilation syndrome Late-onset central hypoventilation with hypothalamic dysfunction Idiopathic central alveolar hypoventilation Sleep-related hypoventilation due to a medication or substance Sleep-related hypoventilation due to a medical disorder Sleep-related hypoxemia disorder Sleep-related hypoxemia Isolated symptoms and normal variants Snoring Catathrenia Central disorders of hypersomnolence Disorders Narcolepsy type 1 Narcolepsy type 2 Idiopathic hypersomnia Kleine–Levin syndrome Hypersomnia due to a medical disorder Hypersomnia due to a medication or substance Hypersomnia associated with a psychiatric disorder Insufficient sleep syndrome Isolated symptoms and normal variants Long sleeper Circadian rhythm sleep–wake disorders Disorders Delayed sleep–wake phase disorder Advanced sleep–wake phase disorder Irregular sleep–wake rhythm disorder Non-24-h sleep–wake rhythm disorder Shift work disorder Jet lag disorder Circadian sleep–wake disorder not otherwise specified (NOS) Parasomnias NREM-related parasomnias Disorders of arousal (from NREM sleep) Confusional arousals Sleepwalking Sleep terrors
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Table 1 (continued ) Sleep-related eating disorder REM-related parasomnias REM sleep behavior disorder Recurrent isolated sleep paralysis Nightmare disorder Other parasomnias Exploding head syndrome Sleep-related hallucinations Sleep enuresis Parasomnia due to a medical disorder Parasomnia due to a medication or substance Parasomnia, unspecified Isolated symptoms and normal variants Sleep talking Sleep-related movement disorders Disorders Restless legs syndrome Periodic limb movement disorder Sleep-related leg cramps Sleep-related bruxism Sleep-related rhythmic movement disorder Benign sleep myoclonus of infancy Propriospinal myoclonus at sleep onset Sleep-related movement disorder due to a medical disorder Sleep-related movement disorder due to a medication or substance Sleep-related movement disorder, unspecified Isolated symptoms and normal variants Excessive fragmentary myoclonus Hypnagogic foot tremor and alternating leg muscle activation Sleep starts (Hypnic Jerks) Other sleep disorder
migraine was associated with insomnia in 68 female patients. Calhoun et al.31 studied 177 females with transformed migraine (TM) and reported that nonrestorative sleep was a prevalent comorbid condition in women with TM. Behavioral therapy for insomnia may cause TM to revert back to episodic migraine.32
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.33–35 Habitual snoring was also associated with morning headache in a study of 268 patients done by Chen et al.36 Bed partners of habitual snorers were also found to have a higher prevalence of morning headaches.37 Scher et al.38 found increase snoring in 2757 patients with chronic daily headache. A higher prevalence of obstructive sleep apnea has been noted in cluster headache in a number of case reports.39–42 Increase in central apnea was demonstrated by Evers et al.43 in patients with active cluster headaches. Treatment with positive airway pressure was associated with improvement in cluster headache in most44–46 but not all43 studies. On the other hand, other studies have not shown a relationship between sleep-disordered breathing and morning headaches.47,10 However, a study showing no difference in severity of obstructive sleep apnea in patients with or without migraine found an improvement in headaches in patients who were treated with positive airway pressure.48 In a cross-sectional
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population-based study of 4000 patients utilizing questionnaires, Kristiansen et al. did not find an increased prevalence in migraine with or without aura and obstructive sleep apnea. There was also no relationship to sleep apnea severity.49 Prevalence of tension-type headache was also not increased compared to controls.50
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 frequency of headaches in patients with narcolepsy, but there are conflicting data regarding the increase in migraine frequency.53,54
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 changes in dorsal pons, hypothalamus, and rostral limbic structures; acute, periodic, or chronic circadian desynchrony; and dysfunction of the whole or part of the RHP axis, supports involvement in the pathophysiology of primary headaches.56 The occurrence of cluster headaches at fixed times every day during an episode is well known.57 Alteration of circadian secretion of melatonin and cortisol has been found.58 There is a circadian pattern to the timing of migraine attacks.59 Hypnic headache occurs at a fixed time after sleep onset.60 Melatonin may be effective in different headache types, including cluster61,62 and hypnic headaches.63 There are conflicting studies in migraine.64,65 Some of these studies support a circadian involvement in primary headaches.
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 disability.68 Characteristic dream patterns were described in 22 patients with migraines by Lippman.69 Dreams preceding migraine have mainly negative content as reported by Levitan70 and by Heather-Greene et al.71 Dream-enactment behavior had a higher prevalence in 161 migraine patients with impaired sleep and severe headache-related disability in patients as reported by Suzuki et al.72 Elementary visual geometric patterns resembling migraine auras were incorporated into dreams preceding migraines.73
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
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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 with RLS and high prevalence of migraine in RLS patients.76 Cologno et al. found that the chances of having RLS in migraine patients were more than 5 times higher in the presence of dopaminergic premonitory symptoms.77 Bruxism can be associated with headaches.78
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 sleepiness. The history is focused on determining these factors. A history of sleep and wake habits and factors that can contribute to disruption of sleep (e.g., caffeine, tobacco, and alcohol) are important.80 The sleep environment is another factor that should be assessed. The comfort of the bed, disruption of sleep from noise, temperature, children, pets, and bed partner are the important factors. Television, radio, or computers in the bedroom may also be distractions to sleep and their presence should be ascertained.79,80 Physical examination includes general and neurological assessment. In sleep-disordered breathing, the focus should be on the upper airway and neck.79 More extensive neurological evaluation is important in sleep-related movement disorders, parasomnias, and hypersomnias. Questionnaires and sleep logs can be useful. There are numerous validated scales used in sleep medicine that may be used for screening.81 Many are focused on particular areas such as insomnia,82 sleep apnea,83,84 or restless legs syndrome.74 The Pittsburgh Sleep Quality Index is a validated instrument that assesses sleep quality and disturbances over the previous month.85 The Functional Outcomes of Sleep Questionnaire is used to evaluate the impact of sleepiness on activities of daily living.86 The Epworth Sleepiness Scale (ESS) consists of questions assessing sleepiness. There are 8 daytime situations in which it is asked what are the chances of dozing.87 The Stanford Sleepiness Scale is a self-rating of sleepiness at the time asked. There are 7 choices ranging from full alertness to inability to stay awake.88 These scales are helpful in both clinical evaluation and response to therapy. Nocturnal Polysomnography is used in the sleep laboratory to evaluate sleep disorders. It is normally indicated for diagnosing sleep-related breathing disorders, to administer positive airway pressure, for evaluating narcolepsy and other hypersomnias, and to assess unusual or atypical parasomnias-especially when violent or injurious behaviors occur during sleep. It is not Table 2 International restless legs study group diagnostic criteria. Adapted from International restless legs syndrome study group.74 1. An urge to move the legs usually but not always accompanied by or felt to be caused by uncomfortable and unpleasant sensations in the legs. 2. The urge to move the legs and any accompanying unpleasant sensations begin or worsen during periods of rest or inactivity such as lying down or sitting. 3. The urge to move the legs and any accompanying unpleasant sensations are partially or totally relieved by movement, such as walking or stretching, at least as long as the activity continues. 4. The urge to move the legs and any accompanying unpleasant sensations during rest or inactivity only occur or are worse in the evening or night than during the day. 5. The occurrence of the above features is not solely accounted for as symptoms primary to another medical or a behavioral condition (e.g., myalgia, venous stasis, leg edema, arthritis, leg cramps, positional discomfort, and habitual foot tapping.)55
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indicated in chronic lung disease, typical or noninjurious parasomnias, seizures without sleep disturbance, restless legs, circadian rhythm disorders, insomnia, or to diagnose depression.89 Physical measurements include electroencephalography, electrooculography, chin electromyography, airflow, nasal pressure, respiratory effort, arterial oxygen saturation, electrocardiography, and electromyography of the lower extremities.90 Portable sleep studies can be done in the home, mainly to diagnose sleep apnea in patients who screen positively for sleep apnea and have no other underlying sleep disorders or severe cardiac pulmonary disease.91 Actigraphy allows for longer evaluation of sleep–wake cycles. It may be useful for insomnia and circadian rhythm disorders.92 The device is a small motion detector worn on the wrist usually for 1–2 weeks.93 A quick screening tool from the pediatric literature uses a pneumonic BEARS. It consists of asking about bedtimes, excessive daytime sleepiness, arousals, duration of sleep, regularity of sleep, and snoring.94 This may be useful for adult patients but has not been validated.
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 positively can be further evaluated or referred to a sleep specialist. References 1. Alberti A. Headache and sleep. Sleep Med Rev. 2006;10(6):431–437. http://dx.doi.org/10.1016/j.smrv.2006.03.003. 2. Victor TW, Hu X, Campbell JC, Buse DC, Lipton RB. Migraine prevalence by age and sex in the United States: a lifespan study. Cephalalgia. 2010;30(9):1065–1072. 3. Westergaard ML, Glümer C, Hansen EH, Jensen RH. Prevalence of chronic headache with and without medication overuse: associations with socioeconomic position and physical and mental health status. Pain. 2014;155(10): 2005–2013. 4. Jennum P, Riha RL. Epidemiology of sleep apnoea/hypopnoea syndrome and sleep-disordered breathing. Eur Respir J. 2009;33(4):907–914. 5. Koo BB. Restless legs syndrome: relationship between prevalence and latitude. Sleep Breath. 2012;16(4):1237–1245. 6. Richey SM, Krystal AD. Pharmacological advances in the treatment of insomnia. Curr Pharm Des. 2011;17(15): 1471–1475. 7. Roth T. Prevalence, associated risks, and treatment patterns of insomnia. J Clin Psychiatry. 2005;66(suppl 9):10–13. 8. Singh NN, Sahota P. Sleep-related headache and its management. Curr Treat Options Neurol. 2013;15(6):704–722. 9. Rains JC, Poceta JS, Penzien DB. Sleep and headaches. Curr Neurol Neurosci Rep. 2008;8(2):167–175. 10. Aldrich MS, Chauncey J. Are morning headaches part of obstructive sleep apnea syndrome?. Arch Intern Med. 1990;150:1265–1267. 11. Evans RW, Dodick DW, Schwedt TJ. The headaches that awaken us. Headache. 2006;46(4):678–681. 12. Cortelli P, Pierangeli G. Hypothalamus and headaches. Neurol Sci. 2007;28(suppl 2):S198–S202. 13. Sateia M, ed. International Classification of Sleep Disorders: Diagnostic and coding manual. 2nd ed. Westchester, IL: American Academy of Sleep Medicine; 2005. 14. Sateia M, editor. International Classification of Sleep Disorders. 3rd ed. Darien: American Academy of Sleep Medicine; 2014. 15. Aguggia M, Cavallini M, Divito N, et al. Sleep and primary headaches. Neurol Sci. 2011;32(suppl 1):S51–S54. 16. Rains JC, Poceta JS. Sleep and headache disorders: clinical recommendations for headache management. Headache. 2006;46(suppl 3):S147–S148. 17. Inamorato E, Minatti-Hannuch SN, Zukerman E. The role of sleep in migraine attacks. Arq Neuropsiquiatr. 1993;51(4): 429–432. 18. Evers S. Sleep and headache: the biological basis. Headache. 2010;50(7):1246–1251. 19. Dodick DW, Eross EJ, Parish JM, Silber M. Clinical, Anatomical, and physiologic relationship between sleep and headache. Headache. 2002;43(3):282–292. 20. Paiva T, Batista A, Martins P, Martins A. The relationship between headaches and sleep disturbances. Headache. 1995;35(10):590–596. 21. Odegard SS, Engstrom M, Sand T, et al. Associations between sleep disturbance and primary headaches: the third Nord-Trøndelag Health Study. J Headache Pain. 2010;11(3):197–206.
T. Freedom / Disease-a-Month 61 (2015) 240–248
247
22. Sancisi E, Cevoli S, Vignatelli L, et al. Increased prevalence of sleep disorders in chronic headache: a case–control study. Headache. 2010;50(9):1464–1472. 23. Vgontzas A, Cui L, Merikangas KR. Are sleep difficulties associated with migraine attributable to anxiety and depression? Headache. 2008;48(10):1451–1459. 24. Bruni O, Fabrizi P, Ottaviano S, et al. Prevalence of sleep disorders in children and adolescents with headache: a case control study. Cephalalgia. 1997;17(4):492–498. 25. Raskin NH. The hypnic headache syndrome. Headache. 1988;28(8):534–536. 26. Liang J-F, Wang S-J. Hypnic headache: a review of clinical features, therapeutic options and outcomes. Cephalalgia. 2014;34(10):795–805. 27. Diener H-CC, Obermann M, Holle D. Hypnic headache: clinical course and treatment. Curr Treat Options Neurol. 2012;14(1):15–26. 28. Uhlig BL, Engstrøm M, Ødegård SS, Hagen KK, Sand T. Headache and insomnia in population-based epidemiological studies. Cephalalgia. 2014;34(10):745–751. 29. Lovati C, D’Amico D, Bertora P, et al. Correlation between presence of allodynia and sleep quality in migraineurs. Neurol Sci. 2010;31(suppl 1):S155–S158. 30. Alstadhaug K, Salvesen R, Bekkelund S. Insomnia and circadian variation of attacks in episodic migraine. Headache. 2007;47(8):1184–1188. 31. Calhoun AH, Ford S, Finkel AG, Kahn Ka, Mann JD. The prevalence and spectrum of sleep problems in women with transformed migraine. Headache. 2006;46(4):604–610. 32. Calhoun AH, Ford S. Behavioral sleep modification may revert transformed migraine to episodic migraine. Headache. 2007;47(8):1178–1183. 33. Poceta JS, Dalessio DJ. Identification and treatment of sleep apnea in patients with chronic headache. Headache. 1995;35(10):586–589. 34. Loh NK, Dinner DS, Foldvary N, Skobieranda F, Yew WW. Do patients with obstructive sleep apnea wake up with headaches? Arch Intern Med. 1999;159(15):1765–1768. 35. Neau JP, Paquereau J, Bailbe M, Meurice JC, Ingrand P, Gil R. Relationship between sleep apnoea syndrome, snoring and headaches. Cephalalgia. 2002;22(5):333–339. 36. Chen P-K, Fuh J-L, Lane H-Y, Chiu P-Y, Tien H-C, Wang S-J. Morning headache in habitual snorers: frequency, characteristics, predictors and impacts. Cephalalgia. 2011;31(7):829–836. 37. Seidel S, Frantal S, Oberhofer P, et al. Morning headaches in snorers and their bed partners: a prospective diary study. Cephalalgia. 2012;32(12):888–895. 38. Scher AI, Lipton RB, Stewart WF. Habitual snoring as a risk factor for chronic daily headache. Neurology. 2003;60(8): 1366–1368. 39. Kudrow L, McGinty DJ, Phillips ER, et al. Sleep apnea in cluster headache. Cephalalgia. 1984;4(1):33–38. 40. Chervin RD, Zallek SN, Lin X, Hall JM, Sharma N, Hedger KM. Sleep disordered breathing in patients with cluster headache. Neurology. 2000;54(12):2302–2306. 41. Nobre ME, Filho PFM, Dominici M. Cluster headache associated with sleep apnoea. Cephalalgia. 2003;23(4):276–279. 42. Graff-Radford SB, Newman A. Obstructive sleep apnea and cluster headache. Headache. 2004;44(6):607–610. 43. Evers S, Barth B, Frese A, Husstedt I-W, Happe S. Sleep apnea in patients with cluster headache: a case–control study. Cephalalgia. 2014;34(10):828–832. 44. Buckle P, Kerr P, Kryger M. Nocturnal cluster headache associated with sleep apnea. A case report. Sleep. 1993;16(5): 487–489. 45. Zallek SN, Chervin RD. Improvement in cluster headache after treatment for obstructive sleep apnea. Sleep Med. 2000;1(2):135–138. 46. Ludemann P, Frese A, Happe S, Evers S, Lu P. Sleep disordered breathing in patients with cluster headache. Neurology. 2001;56(7):984. 47. Jensen R, Olsborg C, Salvesen R, Torbergsen T, Bekkelund SI. Is obstructive sleep apnea syndrome associated with headache? Acta Neurol Scand. 2004;109(3):180–184. 48. Kallweit U, Hidalgo H, Uhl V, Sándor PS. Continuous positive airway pressure therapy is effective for migraines in sleep apnea syndrome. Neurology. 2011;76(13):1189–1191. 49. Kristiansen HA, Kværner KJ, Akre H, Overland B, Russell MB, Kvaerner KJ. Migraine and sleep apnea in the general population. J Headache Pain. 2011;12(1):55–61. 50. Kristiansen HA, Kvaerner KJ, Akre H, Overland B, Russell MB, Kværner KJ. Tension-type headache and sleep apnea in the general population. J Headache Pain. 2011;12(1):63–69. 51. Barbanti P, Fabbrini G, Aurilia C, Vanacore N, Cruccu G. A case–control study on excessive daytime sleepiness in episodic migraine. Cephalalgia. 2007;27(10):1115–1119. 52. Barbanti P, Aurilia C, Egeo G, Fofi L, Vanacore N. A case–control study on excessive daytime sleepiness in chronic migraine. Sleep Med. 2013;14(3):278–281. 53. Dahmen N, Kasten M, Wieczorek S, Gencik M, Epplen JT, Ullrich B. Increased frequency of migraine in narcoleptic patients: a confirmatory study. Cephalalgia. 2003;23(1):14–19. 54. The DMKG Study Group. Migraine and idiopathic narcolepsy—a case-control study. Cephalalgia 2003;23(8):786–9. 55. Ferrari E, Canepari C, Bossolo PA, et al. Changes of biological rhythms in primary headache syndromes. Cephalalgia. 1963;3(suppl 1):58–68. 56. Deshmukh VD. Retino–hypothalamic–pineal hypothesis in the pathophysiology of primary headaches. Med Hypotheses. 2006;66(6):1146–1151. 57. Waldenlind E. Physiological rhythms in cluster headache. Ital J Neruo Sci. 1999;20(suppl 2):s15–s17. 58. Pringsheim T. Cluster headache: evidence for a disorder of circadian rhythm and hypothalamic function. Can J Neurol Sci. 2002;29(1):33–40. 59. Fox AW, Davis RL. Migraine chronobiology. Headache. 1998;38(6):436–441.
248
T. Freedom / Disease-a-Month 61 (2015) 240–248
60. Dodick DW, Mosek AC, Campbell JK. The hypnic (“alarm clock”) headache syndrome. Cephalalgia. 1998;18(3): 152–156. 61. Peres M, Rozen T. Melatonin in the preventive treatment of chronic cluster headache. Cephalalgia. 2001;21(10): 993–995. 62. Leone M, Damico D, Moschiano F, Fraschini F, Bussone G. Melatonin versus placebo in the prophylaxis of cluster headache: a double-blind pilot study with parallel groups. 1996;11:0–2. 63. Dodick DW. Polysomnography in hypnic headache syndrome. Headache. 2000;40(9):748–752. 64. Peres MFP, Zukerman E, da Cunha Tanuri F, Moreira FR, Cipolla-Neto J. Melatonin, 3 mg, is effective for migraine prevention. Neurology. 2004;63(4):757. 65. Alstadhaug KB, Odeh F, Salvesen R, Bekkelund SI. Prophylaxis of migraine with melatonin: a randomized controlled trial. Neurology. 2010;75(17):1527–1532. 66. Frese A, Summ O, Evers S. Exploding head syndrome: six new cases and review of the literature. Cephalalgia. 2014;34 (10):823–827. 67. Green MW. The exploding head syndrome. Curr Pain Headache Rep. 2001;5(3):279–280. 68. Barabas G, Ferrari M, Matthews WS. Childhood migraine and somnambulism. Neurology. 1983;33(7):948–949. 69. Lippman CW. Recurrent dreams in migraine: an aid to diagnosis. J Nerv Ment Dis. 1954;120(3–4):273–276. 70. Levitan H. Dreams which culminate in migraine headaches. Psychother Psychosom. 1984;41(4):161–166. 71. Heather-Greener GQ, Comstock D, Joyce R. An investigation of the manifest dream content associated with migraine headaches: a study of the dreams that precede nocturnal migraines. Psychother Psychosom. 1996;65(4):216–221. 72. Suzuki K, Miyamoto T, Miyamoto M, et al. Dream-enacting behaviour is associated with impaired sleep and severe headache-related disability in migraine patients. Cephalalgia. 2013;33(10):868–878. 73. Podoll K, Töpper R, Robinson D, Sass H. Recurrent dreams as migraine aura symptoms. Fortschr Neurol Psychiatr. 2000;68(4):145–149. 74. International Restless Legs Syndrome Study Group. 2012 revised international Restless Legs Syndrome Study Group diagnostic criteria. Available at: 〈http://irlssg.org/diagnostic-criteria/〉; 2012. 75. d’Onofrio F, Bussone G, Cologno D, et al. Restless legs syndrome and primary headaches: a clinical study. Neurol Sci. 2008;29(suppl 1):S169–S172. 76. Schürks M, Winter A, Berger K, Kurth T. Migraine and restless legs syndrome: a systematic review. Cephalalgia. 2014;34(10):777–794. 77. Cologno D, Cicarelli G, Petretta V, D’Onofrio F, Bussone G. High prevalence of Dopaminergic Premonitory Symptoms in migraine patients with Restless Legs Syndrome: a pathogenetic link. Neurol Sci. 2008;29(Suppl 1):S166–188. 78. Lucchesi LM, Speciali JG, Santos-Silva R, Taddei JA, Tufik S, Bittencourt LRA. Nocturnal awakening with headache and its relationship with sleep disorders in a population-based sample of adult inhabitants of Sao Paulo City, Brazil. Cephalalgia. 2010;30(12):1477–1485. 79. Mallow B. Approach to the patient with disordered sleep. In: Kryger MH, Roth T, DW, eds. Principles and Practice of Sleep Medicine. 5th ed. St. Louis: Elsevier; 2011:641–646. 80. Chokroverty S. Approach to the patient with sleep complaints. In: Chokroverty S, ed. Sleep Disorders Medicine:Basic Scinece, GTechnical Considertions, and Clinical Aspects. 2nd ed. Boston: Butterworth-Heinemann; 1999:275–285. 81. Senthilvel E, Auckley D, Dasarathy J. Evaluation of sleep disorders in the primary care setting: history taking compared to questionnaires. J Clin Sleep Med. 2011;7(1):41–48. 82. Smith S, Trinder J. Detecting insomnia: comparison of four self-report measures of sleep in a young adult population. J Sleep Res. 2001;10(3):229–235. 83. Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med. 1999;131(7):535–536. 84. Chung F, Yegneswaran B, Liao P, et al. STOP Questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108(5):812–821. 85. Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193–213. 86. Chasens ER, Ratcliffe SJ, Weaver TE. Development of the FOSQ-10: a short version of the functional outcomes of sleep questionnaire. Sleep. 2009;32(7):915–919. 87. Johns MW. A new method for measuting daytime sleepiness: the Epworth Sleepiness Scale. Sleep. 1991;14(6): 540–545. 88. Hoddes EV. Methodology quantification of sleepiness: a new approach. Psychphysiology. 1973;10:431–436. 89. Owens Ja, Dalzell V. Use of the “BEARS” sleep screening tool in a pediatric residents' continuity clinic: a pilot study. Sleep Med. 2005;6(1):63–69. 90. Kushida Ca, Littner MR, Morgenthaler T, et al. Practice parameters for the indications for polysomnography and related procedures: an update for 2005. Sleep. 2005;28(4):499–521. 91. Jafari B, Mohsenin V. Polysomnography. Clin Chest Med. 2010;31(2):287–297. 92. Portable Monitoring Task Force of the American Academy of Sleep Medicine. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. J Clin Sleep Med. 2007;3 (7):737–747. 93. Morgenthaler T, Alessi C, Friedman L, et al. Practice parameters for the use of actigraphy in the assessment of sleep and sleep disorders: an update for 2007. Sleep. 2007;30(4):519–529. 94. Webster JB, Kripke DF, Messin S, Mullaney DJ, Wyborney G. An activity-based sleep monitor system for ambulatory use. Sleep. 1982;5(4):389–399.
