What should you know about you/your child’s sleep and headaches?

☆ Editor’s note: It is clear that sleeping well is good for one’s health. Poor sleep can also exacerbate a headache. As patients move from episodic to chronic headache sleep disturbance is a common unwelcome comorbidity. The authors present the evidence for the connection between sleep and headache and offer practical suggestions for all.

How much sleep is recommended?

The American Academy of Sleep Medicine (AASM) recommends that school-aged children get 9–12 h of sleep a night. Teens should get 8–10 h of sleep at night ( Table 1 ). It can be difficult to fit in that much sleep with school, activities, and homework. Also, teens’ natural body rhythm often drives them to go to bed later and wake up later in the morning, so waking up early to get to school on time can be an additional challenge.

What do you need to tell the clinician about sleep?

In order for your clinician to best help with headaches, it is important to discuss any sleep problems. Talk about bedtime and wake-up time, problems falling asleep, waking up at night, and feeling tired during the day. Also tell your clinician about snoring, teeth grinding, restless feelings in the legs, sleep walking, or frequent nightmares. All of these can be associated with headaches. Finally, it is important to tell your clinician if the headache itself wakes you up in the middle of the night or early in the morning.

What can you do to improve sleep and headache?

The good news is that there are many strategies for helping to improve sleep and headaches. The simplest way to improve sleep is to have a consistent routine around sleep. Try to go to bed at the same time every night during the week and on weekends. It can help to set aside thirty minutes to relax before the time you want to fall asleep. It is especially important to turn off screens (including TV, phone, iPad, games) because research has shown that the blue light from screens can affect your body’s release of melatonin, a brain hormone that helps to regulate sleep, particularly in teens.

What are the treatments available to improve sleep and headache?

Research has shown that a particular type of therapy called Cognitive Behavioral Therapy (CBT) can be helpful for treating both sleep and headache. This type of therapy focuses on identifying how thoughts and feelings affect physical symptoms like headaches and sleep problems. CBT teaches tools to help change negative thoughts and feelings. CBT is the first-line treatment for sleep problems in adults including adults with chronic migraine. It has also been shown to be a helpful treatment for adolescents with both sleep problems and migraine. Talk with your clinician about whether this would be a treatment option for your child.

Treatment

It is crucial to recognize and treat sleep problems in youth with headaches and migraine to potentially diminish the negative impact of headaches on daily functioning. Patient education and lifestyle modification play a significant role in overall success of the treatment. Discussion of sleep habits and sleep disturbances at each visit can facilitate intervention through behavioral changes, pharmacologic intervention, and psychological interventions including cognitive behavior therapy (CBT).

The American Academy of Sleep Medicine (AASM) has issued consensus recommendations for the optimal amount of sleep based on age to promote health and improve headaches ( Table 1 ). This can often be difficult to achieve, particularly for teenagers who naturally have a delayed sleep phase but are often required to wake up early for school. In fact, a cross-sectional internet survey study found that 55% of teens whose schools started at 8:30 am or later reported getting at least 8 h of sleep as recommended by the AASM, compared to 33% of those whose school started before 8:30 am. Interestingly, the duration of sleep is not the only important factor; even after adjusting for hours of sleep, those in the schools with later start time reported lower headache frequency compared to teens with earlier school start time.

Consistency of sleep schedule may also influence headache frequency or severity. This is supported by findings from a study showing peaks in the number of emergency department visits for migraine in September and January, the two times of year that sleep schedules are likely to vary the most as students transition from vacation schedule to school schedule.

Counseling about healthy sleep should therefore include discussion of regularity of sleep in addition to adequate duration, appropriate timing, and good quality. The clinician should brainstorm creative ways to adjust to schedule requirements, avoiding putting blame on the patient or family. Attention to sleep-hygiene has been shown to improve frequency and duration of migraines in children and adolescents.

In addition to discussion of healthy sleep habits, there is growing evidence to suggest that nonpharmacologic treatments including cognitive behavior therapy (CBT) can be helpful for both headache and insomnia. In adults, subjects who participated in CBT reported greater decrease in headache days than those treated with sham control. In a pediatric population, hybrid cognitive behavior therapy (CBT) for migraine and insomnia intervention in adolescents resulted in improvement in headache days, insomnia symptoms, sleep quality, sleep hygiene, and sleep patterns at 3-month follow up. The CBT protocol utilized in this study incorporated sleep hygiene education (promotion of healthy sleep habits), stimulus control (association of the bed with sleep), and sleep restriction (limiting time spent in bed to improve sleep efficiency) in addition to components of CBT pain management protocols (headache education, relaxation training, pleasant activity scheduling and positive thought tracking, and parent operant training).

While extensive review of pharmacologic interventions for sleep is beyond the scope of this chapter, it is worth noting that melatonin may have dual benefit for treatment of both headache and insomnia given its role in maintenance of circadian rhythms and potential analgesic effect in headache. See chapter on nonmedication treatments for more information about melatonin.

Prevalence of sleep disturbance among children and adolescents with headache

A growing body of epidemiologic research has helped to identify sleep disorders that are more common among children with headache. Compared to healthy controls, children and adolescents with headaches of any type have been shown to have higher prevalence of abnormal sleep behaviors including insufficient sleep, co-sleeping, difficulty falling asleep, bedtime anxiety, restless sleep, nighttime wakening, nightmares, and daytime sleepiness.

Prevalence of sleep disorders may vary by headache type. Children with migraine have been shown to have prolonged sleep onset, bedtime resistance, decreased sleep duration, daytime sleepiness, night awakenings, sleep anxiety, parasomnias, and sleep-disordered breathing compared to healthy controls. Children with migraine are also more likely to report snoring, parasomnias, sweating during sleep, and daytime sleepiness than those with “nonmigraine headache” or no headache. In a large population study, adolescents with migraine with aura reported more difficulty maintaining sleep, early morning awakenings, daytime fatigue, and persistent insomnia than those with migraine without aura; however, these associations were not statistically significant after adjusting for anxiety and mood disorders, suggesting that these comorbidities may mediate the relationship between headache and sleep.

Other studies have also reported on the prevalence of parasomnias and other primary sleep disorders in children and adolescents with migraine. Adolescents with chronic migraine were more likely to report history of sleep terrors in childhood compared to those with episodic migraine and healthy controls, while somnambulism is more common among those with migraine compared to nonmigraine headache and healthy controls and more common among those with migraine with aura compared to those without aura.

Headache as a symptom of primary sleep disorders

In addition to the high prevalence of sleep disorders among patients with headaches, it is also important to recognize that headache can be a symptom of primary sleep disorders including obstructive sleep apnea and sleep-disordered breathing. This relationship is well-characterized in adults, with up to 20% of patients with sleep apnea reporting morning headache and up to 14% of those with nocturnal or morning headaches found to have sleep apnea on polysomnography. In the pediatric population, a polysomnographic study found that children with migraine were more commonly affected by sleep-disordered breathing than those with tension headache. The International Classification of Headache Disorders, 3rd Edition (ICHD-3) identifies headache attributed to sleep apnea as a discrete entity characterized by headache on waking, typically with bilateral location, pressing quality, and duration of less than four hours. As this disorder can be readily diagnosed with polysomnography, and effective treatment of the underlying sleep apnea can improve headaches, it is important to recognize sleep apnea as a potential underlying etiology for headache, particularly morning headache.

Bruxism and restless leg syndrome (RLS) have both been reported in association with headaches. Rates of bruxism are high among those with migraine, and children with bruxism have been shown to have higher odds of having headache than those without bruxism. Compared to children without headaches, children with migraine have also been shown to have higher rates of RLS ; additionally, migraine patients with RLS had higher frequency of allodynia, vertigo/dizziness, and frequent nighttime arousals that those without RLS.

Sleep disturbance as a trigger in headache and migraine

Equally important to the association between headache and various sleep disorders disturbance is the provoking role that sleep disturbance can play in headache. Up to 70% of children report sleep disturbances and insufficient sleep as triggers of migraine.

In a population-based study of Spanish adolescents, headache was significantly more frequent among those with poor sleeping habits. Specifically, in multivariate analyses, insomnia (OR 1.7 (95% CI 1.3–2.2)) and sleeping less than 8 h per night (OR 1.4 (95% CI 1.1–1.8)) were significant predictors of headache.

Research suggests that insomnia may contribute to the onset, maintenance, and progression of migraine and other primary headaches. Longitudinal studies of adolescents suggest that insomnia increases risk for the persistence of headache over time as well as progression from episodic to chronic headache. Moreover, early onset sleep disorders have been found to predict headache persistence from infancy to childhood; in one study, 78% of children with enduring headache had early childhood sleep disturbances compared to 25% of children with headache remission.

Headache as a provoking factor for poor sleep

Just as headache may be a consequence of poor sleep, poor sleep may also be driven by headaches. In fact, migraine without aura was found to be a sensitive risk factor for disorders of initiating and maintaining sleep. In a study of 622 children and adolescents with pain syndromes, of which 60% were headache, sleep disturbance was among the most common complaints caused by pain. Actigraphic studies of sleep quality in children and adolescents with migraine have shown mixed results. While one study found that those with headache had less time in quiet motionless sleep and earlier wake times that those without headache, another study found no difference between children with migraine and controls during the interictal period, but did show decrease in nocturnal motor activity in the night preceding a migraine.

Physiology and mechanism of relationship between sleep and headache

The state of sleep encompasses almost one third of a person’s life, and disturbances of sleep often mirror disturbances in the physiology of body and mind. While a growing body of evidence shows the relationship between headache and sleep, potential mechanisms underlying this association have not been established.

One possibility is that headache and sleep disturbance are both manifestations of a similar underlying pathogenesis related to shared neurophysiologic and anatomic pathways. Anatomic substrates for both sleep and headache overlap in the brainstem and diencephalon as do physiologic pathways involving dopamine, orexin, melatonin, and serotonin. These brain structures are crucial to the regulation of sleep and nociception as well migraine pathogenesis.

Primary headaches including migraine and cluster headache are characterized by a striking association with the sleep–wake cycle and other circadian biorhythms, suggesting that they may represent centrally originating chronobiological disorders. The hypothalamus, specifically the suprachiasmatic nuclei (SCN), has been considered to be the site of origin of these rhythms. While the SCN is best known for its role in driving the circadian rhythm, the hypothalamus also has important connections to nociceptive neurons in the locus ceruleus, dorsal raphe nucleus, and periaqueductal gray matter, all of which are integral to the nociceptive pathways involved in pathogenesis of headache. Notably, migraine appears to occur in association with rapid eye movement (REM) sleep, as well as in association with excessive amounts of stage III and stage IV sleep, while chronic paroxysmal hemicrania and cluster headache also characteristically occur during REM sleep.

The dorsal raphe may mediate the relationship between sleep and headache through its role in serotonin metabolism. Serotonin is known to play a role in pathogenesis of headache; pharmacologic serotonin depletion can provoke a migraine, and triptans exert their migraine abortive properties through agonism at the serotonin receptor. Interestingly, activity of the dorsal raphe nucleus is decreased during REM sleep resulting in lower systemic levels of serotonin, which has been proposed to drive the relationship between migraine and REM sleep.

Finally, melatonin metabolism may influence the relationship between headache and sleep. The classic role of melatonin in the nervous system is in maintenance of the circadian rhythm, primarily by promoting sleep onset. However, additional actions include potentiation of gamma aminobutyric acid (GABA), modulation of serotonergic effects on cerebral arteries and inhibition of prostaglandin E2 synthesis, suggesting that it may have additional analgesic properties. In adults, studies have shown reduction in urinary melatonin among patients with migraine including during migraine attacks, and prolonged dim-light melatonin onset has been associated with more frequent migraine days per month among those with chronic migraine. In a pediatric sample, there was no difference in urinary melatonin excretion between children with migraine and healthy controls; however, urinary melatonin excretion was decreased in the night preceding a migraine among those who experienced aura or premonitory symptoms with migraine.