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HEADACHES AND SLEEP Headache is a common complaint for which patients visit their primary care provider. An association between sleep and headache has been recognized in medical literature for many years. Headache and sleep appear to have a bidirectional relationship. Headache has been noted following sleep deprivation, and in some after excess sleep and, conversely, head pain may contribute to awakening and loss of sleep. Headache can be relieved by sleep and it can emerge from sleep. When headaches become frequent (i.e. more than twice a week) then it would be reasonable to look beyond the headache phenomena alone, and best to determine what may be triggering these events more frequently. Problems with sleep are one of the most overlooked factors that can lead to frequent headaches. By identifying and treating a sleep disturbance a patient may find significant improvement in their headaches as well. There are different types of headaches. A full discussion of the various types of headaches is beyond the scope of this article. However, it should be noted that the two main categories of headaches are Migraine and Tension headaches. When either of these occurs daily then a patient is given a diagnosis of Chronic Daily Headaches. Many people have a cross over or overlap between Tension and Migraine headaches. In either case it is important to recognize that a headache patient has an internal set point for the triggers that activate a headache and that when the threshold for the trigger is met then the headache begins. Some medications that treat Migraine headaches, for example, are taken daily in order to raise the triggering threshold and prevent the headache from starting. Sleep duration, sleep quality, sleep timing, and daily stress, all contribute to reaching or avoiding this threshold. There is increasing evidence that headache, particularly morning headache, is a nonspecific symptom of disrupted sleep. Morning headaches are associated with decreased total sleep time, lower sleep efficiency, and lower amounts of rapid eye movement (REM) sleep. Common sleep disorders that are been associated with headache include: Obstructive Sleep Apnea (OSA), bruxism (grinding or clenching of the teeth during sleep), restless legs syndrome / periodic limb movement disorder, insomnia, and irregular sleeping hours. When a person predisposed to headaches become fatigued then this lowers their headache threshold and a headache can be triggered more easily. Therefore, problems that affect daytime energy level and cause fatigue, such as disturbed sleep, can cause headaches to occur more frequently. The enhanced fatigue may develop in the afternoon or late in the day. Insomnia (problems falling asleep or staying asleep) can lead to fatigue. Detailed evaluation of the patients Insomnia can lead to proper treatment, improved rest and reduction or resolution of their frequent headaches. Morning headache is a diagnostic clue that a patient may have Obstructive Sleep Apnea. Obstructive breathing during sleep occurs when a blockage (partial or complete) develops in the back of the throat as the muscles relax during sleep. This results in brief disruptions of sleep brought on by abnormal breathing. The person may or may not be aware of these events. The primary symptoms of a person with OSA are snoring and daytime sleepiness. Morning headaches are also a symptom that should cause suspicion of that the headache sufferer may have Obstructive Sleep Apnea or a related more subtle disorder called the Upper Airway Resistance Syndrome (to be explained in detail in a future segment of the Wake-Up Call section of the Sadler Connection). People at risk for obstructive breathing problems during sleep include individuals with small or recessed jaws, large tongues, large tonsils, high arched palates (roof of the mouth) and those who are obese. Frequently people with these breathing problems will uncontrollably grind or clench their teeth at night while sleeping as the brains attempt to open up the airway by bringing the back of the tongue forward, away from the back of the throat. These individuals develop TMJ (or TMD - Temporal Mandibular Dysfunction) symptoms and can have extensive headache pain. Most Dentists will make a bite splint that helps protect the teeth and reduces the tension on the Temporal Mandibular Joint but does not help the breathing abnormality. By treating the breathing problem the grinding and clenching resolves in many of these patients. Diagnosis and treatment of obstructive breathing during sleep are important, not only to improve the headache, but because people with obstructive breathing during sleep have an increased risk of developing high blood pressure, stroke, or heart disease. An overnight sleep study is a valuable tool in the diagnosis of sleep disorders and can unmask the precipitating abnormality that may be trigger frequent headaches. If you or someone your know suffers from frequent headaches then obtaining a proper evaluation would be appropriate.
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