Repalda, Myca Nicole D.

BSN3

Sleep-related headache and its management

Abstract

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
Repalda, Myca Nicole D. BSN3

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.

Introduction
Headache has been linked to a wide range of sleep disorders in adults,
adolescents, and children. Among patients with migraine and tension type headache,
insomnia is the most common sleep complaint, reported by one-half to two-thirds of
headache clinic patients. One of the largest clinical studies published to date reported
sleep complaints among 1,283 migraineurs presenting for headache treatment. Morning
headaches were reported by 71% of migraineurs. Though insomnia was not
systematically assessed, the majority of patients reported difficulty initiating sleep (53%)
and maintaining sleep (61%). Chronically shortened sleep patterns suggestive of
Repalda, Myca Nicole D. BSN3

insomnia were observed in 38% of migraineurs (< 6 hours sleep per night) and shorter
sleep was associated with greater migraine frequency and severity.

Body
Headache is one of the most common of all human physical complaints. It is
actually a symptom rather than a disease entity. The association between headache and
sleep disorders was recognized well over a century ago and the last quarter century has
brought a marked growth in our society. Headache can have an organic cause or without
a cause. Headache can be associated with brain tumor or an aneurysm. Pain in the head
can occur anytime even at sleep. Sleep complaints such as trouble falling asleep, wake
up several times, trouble staying asleep, or waking after usual amount of sleep feeling
tired or worn have been identified as risk factors for frequent and severe headache
conditions. Headache could lead into insomnia when it triggers at night. As a health care
provider, General Health Assessment is a must since headache can be a presenting
symptom of various physiological or psychological disturbances. A detailed history,
physical assessment and neurologic examination must be done to the patient. Also,
assess for the severity, quality, duration, location of the pain. To relieve the pain of the
client, Analgesics might be given as prescribed.

Conclusion
Therefore, headache can be a triggering factor for sleep disturbances, tardiness,
and daytime sleepiness. It could be a risk factor for thought process anomalies, irritable
and unable to concentrate.

Reference:
1. Singh N., Sahota P. (2013). Sleep-related headache and its management.
Retrieved from: http://europepmc.org/abstract/med/24132786
2. Ranis J. (2010). Sleep and headache Disorders. Retrieved from:
http://www.headachejournal.org/view/0/SleepAndHeadacheDisorders.html