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Sleep-Related Headache and its Management

  • SLEEP DISORDERS (S CHOKROVERTY, SECTION EDITOR)
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Opinion statement

Sleep and headache have both generated curiosity within the human mind for centuries. The relationship between headache and sleep disorders is very complex. While Lieving in 1873 first observed that headaches were linked to sleep, Dexter and Weitzman in 1970 described the relationship between headache and sleep stages. Though our understanding of sleep and headache relationship has improved over the years with expanding knowledge in both fields and assessment tools such as polysomnography, it is still poorly understood. Headache and sleep have an interdependent relationship. Headache may be intrinsically related to sleep (migraine with and without aura, cluster headache, hypnic headache, and paroxysmal hemicrania), may cause sleep disturbance (chronic migraine, chronic tension-type headache, and medication overuse headache) or a manifestation of a sleep disorder like obstructive sleep apnea. Headache and sleep disorder may be a common manifestation of systemic dysfunction-like anemia and hypoxemia. Headaches may occur during sleep, after sleep, and in relation to different sleep stages. Lack of sleep and excessive sleep are both considered triggers for migraine. Insomnia is more common among chronic headache patients. Experimental data suggest that there is a common anatomic and physiologic substrate. There is overwhelming evidence that cluster headache and hypnic headaches are chronobiological disorders with strong association with sleep and involvement of hypothalamus. Cluster headache shows a circadian and circannual rhythmicity while hypnic headache shows an alarm clock pattern. There is also a preferential occurrence of cluster headache, hypnic headache, and paroxysmal hemicrania during REM sleep. Silencing of anti-nociceptive network of periaqueductal grey (PAG), locus ceruleus and dorsal raphe nucleus doing REM sleep may explain the preferential pattern. Sleep related headaches can be classified into (1) headaches with high association with obstructive sleep apnea, which includes cluster headache, hypnic headache, and headache related to obstructive sleep apnea; and (2) headaches with high prevalence of insomnia, medication overuse, and psychiatric comorbidity including chronic migraine and chronic tension-type headache. The initial step in the management of sleep related headache is proper diagnosis with exclusion of secondary headaches. Screening for sleep disorders with the use of proper tests including polysomnography and referral to sleep clinic, when appropriate is very helpful. Control of individual episode in less than 2 hours should be the initial goal using measures to abort and prevent a relapse. Cluster headache responds very well to injectable Imitrex and oxygen. Verapamil, steroids and lithium are used for preventive treatment of cluster headache. Intractable cluster headache patients have responded to hypothalamic deep brain stimulation. Hypnic headache patients respond to nightly caffeine, indomethacin, and lithium. Paroxysmal hemicrania responds very well to indomethacin. Early morning headaches associated with obstructive sleep apnea respond to CPAP or BiPAP with complete resolution of headache within a month. Patient education and lifestyle modification play a significant role in overall success of the treatment. Chronic tension-type headache and chronic migraine have high prevalence of insomnia and comorbid psychiatric disorders, which require behavioral insomnia treatment and medication if needed along with psychiatric evaluation. Apart from the abortive treatment tailored to the headache types, - such as triptans and DHE 45 for migraine and nonsteroidal anti-inflammatory medication for chronic tension-type headache, preventive treatment with different class of medications including antiepileptics (Topamax and Depakote), calcium channel blockers (verapamil), beta blockers (propranolol), antidepressants (amitriptyline), and Botox may be used depending upon the comorbid conditions.

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References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance, •• Of major importance

  1. Stovner L, Hagen K, Jensen R, et al. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia. 2007;27(3):193–210.

    Article  PubMed  Google Scholar 

  2. Sjaastad O, Bakketeig LS. Cluster headache prevalence. Vaga study of headache epidemiology. Cephalalgia. 2003;23(7):528–33.

    Article  PubMed  CAS  Google Scholar 

  3. Paiva T, Batista A, Martins P, Martins A. The relationship between headaches and sleep disturbances. Headache. 1995;5(10):590–6.

    Article  Google Scholar 

  4. Rains JC, Poceta JS, Penzien DB. Sleep and headaches. Curr Neurol Neurosci Rep. 2008;8(2):167–75.

    Article  PubMed  Google Scholar 

  5. Nobre ME, Leal AJ, Filho PM. Investigation into sleep disturbance of patients suffering from cluster headache. Cephalalgia. 2005;25(7):488–92.

    Article  PubMed  CAS  Google Scholar 

  6. Mitsikostas DD, Vikelis M, Viskos A. Refractory chronic headache associated with obstructive sleep apnoea syndrome. Cephalalgia. 2008;28(2):139–43.

    PubMed  CAS  Google Scholar 

  7. Vgontzas A, Cui L, Merikangas KR. Are sleep difficulties associated with migraine attributable to anxiety and depression? Headache. 2008;48(10):1451–9.

    Article  PubMed  Google Scholar 

  8. Ohayon MM. Prevalence and risk factors of morning headaches in the general population. Arch Intern Med. 2004;164(1):97–102.

    Article  PubMed  Google Scholar 

  9. Barbanti P, Fabbrini G, Aurilia C, et al. A case-control study on excessive daytime sleepiness in episodic migraine. Cephalalgia. 2007;27(10):1115–9.

    Article  PubMed  CAS  Google Scholar 

  10. Silberstein SD, Lipton RB, Dalessio DJ. Overview, diagnosis, and classification of headache. In: Silberstein SD, Lipton RB, Dodick DW, (Eds). Wolff’s headache and other head pain. 8th edition. Oxford University Press; 2007.

  11. Rains JC, Poceta JS. Sleep-related headaches. Neurol Clin. 2012;30(4):1285–98. A comprehensive review describing the relationship between sleep and headache and its implication in the management of sleep-related headaches.

    Article  PubMed  Google Scholar 

  12. Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders, second edition. Cephalalgia. 2004;24 Suppl 1:1–151.

    Google Scholar 

  13. Alberti A, Mazzotta G, Gallinella E, et al. Headache characteristics in obstructive sleep apnea and insomnia. Acta Neurol Scand. 2005;111:309–16.

    Article  PubMed  CAS  Google Scholar 

  14. Dexter JD, Weitzman ED. The relationship of nocturnal headaches to sleep headaches to sleep stage patterns. Neurology. 1970;20:413–519.

    Article  Google Scholar 

  15. Fox AW, Davis RL. Migraine chronobiology. Headache. 1998;38(6):436–41.

    Article  PubMed  CAS  Google Scholar 

  16. Goder R, Fritzer G, Kapsokalvyas A, et al. Polysomnographic findings in nights preceding a migraine attack. Cephalalgia. 2001;21:31–7.

    Article  PubMed  CAS  Google Scholar 

  17. Ødegård SS, Engstrøm M, Sand T, Stovner LJ, Zwart JA, Hagen K. Associations between sleep disturbance and primary headaches: the third Nord-Trøndelag Health Study. J Headache Pain. 2010;11(3):197–206.

    Article  PubMed  Google Scholar 

  18. Raskin NH. The hypnic headache syndrome. Headache. 1988;28:534–6.

    Article  PubMed  CAS  Google Scholar 

  19. Evers S, Goadsby PJ. Hypnic headache: clinical features, pathophysiology, and treatment. Neurology. 2003;60(6):905–9.

    Article  PubMed  Google Scholar 

  20. Pinessi L, Rainero I, Cicolin A, et al. Hypnic headache syndrome: association with REM sleep. Cephalalgia. 2003;23:150–4.

    Article  PubMed  CAS  Google Scholar 

  21. Dodick DW, Mosek AC, Campbell JK. The hypnic (‘alarm clock’) headache syndrome. Cephalalgia. 1998;18:152–6.

    Article  PubMed  CAS  Google Scholar 

  22. Holle D, Wessendorf TE, Zaremba S, et al. Serial polysomnography in hypnic headache. Cephalalgia. 2011;31(3):286–90.

    Article  PubMed  Google Scholar 

  23. Kayed K, Godtlibsen OB, Sjaastad O. Chronic paroxysmal hemicranias IV: “REM sleep locked” nocturnal headache attacks. Sleep. 1978;1(1):91–5.

    PubMed  CAS  Google Scholar 

  24. Kayed K, Sjaastad O. Nocturnal and early morning headaches. Ann Clin Res. 1985;17:243–6.

    PubMed  CAS  Google Scholar 

  25. Karli N, Zarifoglu M, Calisir N, Akgoz S. Comparison of pre-headache phases and trigger factors of migraine and episodic tension-type headache: do they share similar clinical pathophysiology? Cephalalgia. 2005;25(6):444–51.

  26. Sachs C, Svanborg E. The exploding head syndrome: polysomnographic recordings and therapeutic suggestions. Sleep. 1991;14(3):263–6.

    PubMed  CAS  Google Scholar 

  27. Tepper SJ, Stewart WJ. Medication-overuse headache. Continuum. 2012:18(4):807–22. This is a nice review article describing the clinical features of medication overuse headache, pathophysiology, prevention, and treatment.

    PubMed  Google Scholar 

  28. Calhoun AH, Ford S. Behavioral sleep modification may revert transformed migraine to episodic migraine. Headache. 2007;47(8):1178–83.

    Article  PubMed  Google Scholar 

  29. Graham JR, Wolff HG. Mechanism of migraine headache and action of ergotamine tartrate. Arch Neurol Psychiatry. 1938;39:737.

    Article  CAS  Google Scholar 

  30. Rizzoli PB. Acute and preventive treatment of migraine. Continuum. 2012:18(4):764–82. Nice review article on prevention and treatment of migraine.

    PubMed  Google Scholar 

  31. Loder E. Triptan therapy in migraine. N Engl J Med. 2010;363(1):63–70. Nice review article describing the therapeutic value of Triptans in the treatment of acute migraine attacks.

    Article  PubMed  CAS  Google Scholar 

  32. Ferrari MD, Goadsby PJ, Roon KI, Lipton RB. Triptans (serotonin, 5-HT1B/1D agonists) in migraine: detailed results and methods of a meta-analysis of 53 trials. Cephalalgia. 2002;22(8):633–58.

    Article  PubMed  CAS  Google Scholar 

  33. Baron EP, Tepper SJ. Revisiting the role of ergots in the treatment of migraine and headache. Headache. 2010;50(8):1353–61.

    Article  PubMed  Google Scholar 

  34. Saper JR, Silberstein S. Pharmacology of Dihydroergotamine and evidence for efficacy and safety in migraine. Headache. 2006;46(4):S171–81.

    Article  PubMed  Google Scholar 

  35. Klapper JA, Stanton J. Clinical experience with patient administered subcutaneous Dihydroergotamine mesylate in refractory headaches. Headache. 1992;32(1):21–3.

    Article  PubMed  CAS  Google Scholar 

  36. Ramadan NM. Current trends in migraine prophylaxis. Headache. 2007;47 Suppl 1:S52–7.

    Article  PubMed  Google Scholar 

  37. Solomon S. Major therapeutic advances in the past 25 years. Headache. 2007;47 Suppl 1:S20–2.

    Article  PubMed  Google Scholar 

  38. Evans RW, Rizzoli P, Loder E, Bana D. Beta-blockers for migraine. Headache. 2008;48(3):455–60.

    Article  PubMed  Google Scholar 

  39. Dodick DW, Smith TR, Becker WJ, et al. Botulinum neurotoxin type A for treatment of chronic migraine: PREEMPT 2 trial double-blind phase. Presented at: the International Headache Congress; Philadelphia, Pennsylvania; September 9–13, 2009.

  40. Mauskop A. Nonmedication, alternatives, and complimentary treatments for migraine. Continuum. 2012:18(4):796–806. The efficacy of some of the nonpharmacologic therapies including biofeedback, relaxation technique, herbal medications, and vitamins in the treatment of migraine.

    PubMed  Google Scholar 

  41. Ho TW, Ferrari MD, Dodick DW, Galet V, Kost J, Fan X, et al. Efficacy and tolerability of MK-0974 (telcagepant), a new oral antagonist of calcitonin gene-related peptide receptor, compared with Zolmitriptan for acute migraine: a randomized, placebo-controlled, parallel-treatment trial. Lancet. 2008;372(9656):2115–23.

    Article  PubMed  CAS  Google Scholar 

  42. Färkkilä M, Diener HC, Géraud G, Láinez M, Schoenen J, Harner N, et al. COL MIG-202 study group. Efficacy and tolerability of lasmiditan, an oral 5-HT(1F) receptor agonist, for the acute treatment of migraine: a phase 2 randomized, placebo-controlled, parallel-group, dose-ranging study. Lancet Neurol. 2012;11(5):405–13. Oral lasmiditan, a highly selective 5 HT 1F receptor agonist without vasoconstrictor activity is safe and effective in the acute treatment of migraine.

    Article  PubMed  Google Scholar 

  43. Bartsch T, Paemeleire K, Goadsby PJ. Neurostimulation approaches to primary headache disorders. Curr Opin Neurol. 2009;22(3):262–8.

    Article  PubMed  Google Scholar 

  44. Jürgens TP, Leone M. Pearls and pitfalls: neurostimulation in headache. Cephalalgia. 2013;33(8):512–25.

    Article  PubMed  Google Scholar 

  45. Saper JR, Dodick DW, Silberstein SD, McCarville S, Sun M, Goadsby PJ. ONSTIM Investigators. Occipital nerve stimulation for the treatment of intractable chronic migraine headache: ONSTIM feasibility study. Cephalalgia. 2011;31(3):271–85.

    Article  PubMed  Google Scholar 

  46. Tobin J, Flitman S. Occipital nerve blocks: when and what to inject? Headache. 2009;49:1521–33.

    Article  PubMed  Google Scholar 

  47. Ashkenazi A, Matro R, Shaw JW, et al. Greater occipital nerve block using local anesthetics alone or with triamcinolone for transformed migraine: a randomized comparative study. J Neurol Neurosurg Psychiatry. 2008;79:415–7.

    Article  PubMed  CAS  Google Scholar 

  48. Babineau S, Geen M. Headaches in children. Continuum. 2012:18(4):753–68. Detailed discussion of management of headache in children.

    Google Scholar 

  49. Brandes JL. The influence of estrogen on migraine: a systematic review. JAMA. 2006;295(15):1824–30.

    Article  PubMed  CAS  Google Scholar 

  50. Brandes LS, Green M. Migraine in women. Continuum. 2012:18(4):835–52. Nice review article on the management of headache in women including the role of hormonal manipulation.

    PubMed  Google Scholar 

  51. Dodick DW, Capobianco DJ. Treatment and management of cluster headache. Curr Pain Headache Rep. 2001;5(1):83–91.

    Article  PubMed  CAS  Google Scholar 

  52. Nesbitt AD, Goadsby PJ. Cluster headache. BMJ. 2012(11);344:e2407.

  53. Cohen AS, Burns B, Goadsby PJ. High-flow oxygen for treatment of cluster headache: a randomized trial. JAMA. 2009;302(22):2451–7.

    Article  PubMed  CAS  Google Scholar 

  54. Cittadini E, May A, Straube A, Evers S, Bussone G, Goadsby PJ. Effectiveness of intranasal Zolmitriptan in acute cluster headache: a randomized, placebo-controlled, double-blind crossover study. Arch Neurol. 2006;63(11):1537–42.

    Article  PubMed  Google Scholar 

  55. van Vliet JA, Bahra A, Martin V, Ramadan N, Aurora SK, Mathew NT, et al. Intranasal Sumatriptan in cluster headache: randomized placebo-controlled double-blind study. Neurology. 2003;60(4):630–3.

    Article  PubMed  Google Scholar 

  56. Bussone G, Leone M, Peccarisi C, Micieli G, Granella F, Magri M, et al. Double blind comparison of lithium and verapamil in cluster headache prophylaxis. Headache. 1990;30(7):411–7.

    Article  PubMed  CAS  Google Scholar 

  57. Goadsby PJ. Trigeminal autonomic Cephalalgias. Continuum. 2012;18(4):883–95. A nice review article on the management of cluster headache, paroxysmal hemicranias, and other trigeminal autonomic Cephalalgia.

    PubMed  Google Scholar 

  58. Cohen AS, Matharu MS, Goadsby PJ. Electrocardiographic abnormalities in patients with cluster headache on verapamil therapy. Neurology. 2007;69(7):668–75.

    Article  PubMed  CAS  Google Scholar 

  59. Leone M, Proietti Cecchini A, Franzini A, Broggi G, Cortelli P, Montagna P, et al. Lessons from 8 years’ experience of hypothalamic stimulation in cluster headache. Cephalalgia. 2008;28(7):787–97.

    Article  PubMed  CAS  Google Scholar 

  60. Burns B, Watkins L, Goadsby PJ. Treatment of medically intractable cluster headache by occipital nerve stimulation: long-term follow-up of eight patients. Lancet. 2007;369(9567):1099–106.

    Article  PubMed  Google Scholar 

  61. Donnet A, Lantéri-Minet M. A consecutive series of 22 cases of hypnic headaches in France. Cephalalgia. 2009;29:928–34. This study is one of the three case series reported since the individualization of HH by ICHD-II, including a field testing of ICHD-II criteria.

    Article  PubMed  CAS  Google Scholar 

  62. Lanteri-Minet M, Donnet A. Hypnic headache. Curr Pain Headache Rep. 2010;14(4):309–15.

    Article  PubMed  Google Scholar 

  63. Morgenthaler TI, Kapen S, Lee-Chiong T, Alessi C, Boehlecke B, Brown T, et al. Standards of practice committee; American Academy of Sleep Medicine. Practice parameters for the medical therapy of obstructive sleep apnea. Sleep. 2006;29(8):1031–5.

    PubMed  Google Scholar 

  64. Nath Zallek S, Chervin RD. Improvement in cluster headache after treatment for obstructive sleep apnea. Sleep Med. 2001;1(2):135–8.

    Article  Google Scholar 

  65. Kiely JL, Murphy M, McNicholas WT. Subjective efficacy of nasal CPAP therapy in obstructive sleep apnoea syndrome: a prospective controlled study. Eur Respir J. 1999;13(5):1086–90.

    Article  PubMed  CAS  Google Scholar 

  66. Kaniecki RG. Tension-type headache. Continuum. 2012;18(4):823–34. Very nice review article on the management of tension type headache.

    PubMed  Google Scholar 

  67. Fumal A, Schoenen J. Tension-type headache: current research and clinical management. Lancet Neurol. 2008;7(1):70–83.

    Article  PubMed  CAS  Google Scholar 

  68. Schwartz BS, Stewart WF, Simon D, Lipton RB. Epidemiology of tension-type headache. JAMA. 1998;279(5):381–3.

    Article  PubMed  CAS  Google Scholar 

  69. Cohen AS, Kaube H. Rare nocturnal headaches. Curr Opin Neurol. 2004;17(3):295–9.

    Article  PubMed  Google Scholar 

  70. Green MW. The exploding head syndrome. Curr Pain Headache Rep. 2001;5:279–80.

    Article  PubMed  CAS  Google Scholar 

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Pradeep Sahota declares that he has no conflicts of interest. Niranjan N. Singh declares that he has no conflicts of interest.

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  1. Department of Neurology, University of Missouri School of Medicine, University of Missouri Health Care, CE 507, CS & E Building, 1 Hospital Drive, Columbia, MO, 65212, USA

    Niranjan N. Singh MBBS, MD, DM & Pradeep Sahota MD, FAAN, FAASM, FAES, FACP

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  1. Niranjan N. Singh MBBS, MD, DM
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Correspondence to Pradeep Sahota MD, FAAN, FAASM, FAES, FACP.

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Singh, N.N., Sahota, P. Sleep-Related Headache and its Management. Curr Treat Options Neurol 15, 704–722 (2013). https://doi.org/10.1007/s11940-013-0258-1

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