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Case Studies in Headache: Is Sleep Good or Bad for Headaches?

By Mark W. Green, M.D.
Director of Headache Medicine, Clinical Professor of Neurology, Anesthesiology and Dentistry, Columbia University

People often inquire, ”Is sleep good or bad for headaches?” The answer is yes—depending on the circumstances.

CASE 1
A 10-year-old boy came to my office for monthly headaches. They tended to begin at the end of a school day and were pounding in quality. Upon returning home, his mother noted that he looked very ill and he would vomit. After falling asleep in a cool and dark bedroom, he would awaken and tell his mother that his headache was gone and that he was ready for dinner.

Not only is the relationship of sleep to headache complex, but it may change over a lifetime. This is certainly true with migraine.

For children with migraine, there is no medical therapy that has proven to be as effective as sleep. Many migrainous children return home from school looking pale, and complaining of a headache and nausea. Often they vomit, which might help or worsen the headache. If they can fall asleep, even for an hour, this therapy is capable of turning the whole event around. They often awaken well and, in fact, hungry.

This interesting turn of events has confounded researchers trying to develop medications to treat childhood migraine. It has often been the case that children who went to sleep and did not take the experimental medication did better. Note that most of the over-the-counter headache medications contain caffeine, which is not very effective at inducing sleep.

With age, this therapeutic effect disappears. Many adults find that their attacks are affected by sleep, but in a different way. Going to sleep with an untreated migraine is commonly a mistake as it may worsen during the night and become difficult to treat in the morning. If a migraineur is sleep deprived, he or she can expect more migraines, while those who oversleep may wake with attacks that are very resistant to therapy. The explanation for this paradox eludes researchers.

What is clear is that migraine sufferers do not do well with change. Just as they do poorly with oversleeping and under sleeping, changes in the timing of meals, stress level and barometric pressure can trigger migraines. Migraineurs, then, are advised to keep regular sleep schedules and to treat attacks early on.

CASE 2
A 30-year-old male came to my office distraught because he had developed severe headaches that woke him at 2 am, 4 am, and 6 am every night. He described the pain as a ”hot poker behind his right eye.” His right eye filled with tears and his nose became stuffy. The patient was afraid to fall asleep and experience the pain.

This is cluster headache. Individuals with this extremely painful headache are commonly awakened by attacks in the middle of the night, often at precisely the same time, inspiring an old term ”alarm clock headaches.” The patient will need to seek the care of a headache specialist and be placed on medication to minimize these attacks.

CASE 3

A 66-year old woman came to my office, noting that she was awakened at 5 am daily with a throbbing headache across her forehead. She described it as 6 out of 10 in severity. The headaches also occurred on occasion when she napped. The pain lasted two hours. She wasn’t nauseated or sensitive to lights during these attacks and had no history of migraine. Her neurological examination and a CT scan of the head were normal.

Some rarer headache syndromes are specifically related to sleep. Hypnic headaches, which this patient had, present generally in the elderly, and more commonly in women than men. People with hypnic headache often wake nightly with a generalized throbbing headache. Various medications, including lithium carbonate and caffeine, can actually prevent these attacks.

CASE 4
A 72-year-old woman came to my office with attacks that woke her out of a sound sleep at 3:00 am and 4:30 am every morning. She described the attacks as a loud explosion in her head. She was very frightened by these spells, but actually denied having any head pain.

This odd and rare syndrome is called exploding head syndrome. It is not actually a pain disorder, but rather a sleep disorder, although individuals may seek help at a headache center. They complain of an explosive sound in the head each night that is loud and frightening. This syndrome is often treated with clomipramine.

Many other neurological and medical illnesses can be associated with headaches and sleep, and these often have very different mechanisms and treatments. There are various sleep disturbances, for example, that can contribute to headaches. Sleep apnea syndrome, which is commonly associated with being overweight, snoring at night, and being tired throughout that day, can also be associated with headaches. The mechanism for this relationship is not entirely understood, but when this syndrome is identified and treated, chronic headaches may significantly diminish.

Another common sleep disorder is restless legs syndrome (RLS). Individuals with RLS have an uncomfortable sensation that they need to move their legs, particularly at night. As a result, they may suffer from fragmented sleep, which can lead to a worsening of a headache problem.

Finally, individuals with painful medical illnesses such as fibromyalgia often complain of aching pain in the front of the head, which is perhaps a manifestation of impaired sleep. Anxiety and depression, often associated with problems in falling asleep or staying asleep, are also commonly associated with a similar head pain.

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