**CASE 2.**

*Chronic tension-type headache.*

*Sleep Patterns Changes Depending on Headache Subtype and Covariates of Primary Headache… DOI: http://dx.doi.org/10.5772/intechopen.106497*

## **4.3 Cluster headache**

Cluster headache is one of the trigeminal autonomic cephalalgias. Pain is mainly located at orbital/supraorbital/temporal regions unilaterally. The duration of severe pain is 15 to 180 minutes with accompanying autonomic symptoms (ICD). The relation with sleep and cluster headache [CH] has been shown in previous studies. CH is thought to be provoked during the switching of REM sleep to NonREM sleep. In episodic CH, attacks are mainly related to REM sleep, though this relaton is not clear in chronic form [8].

Sleep apnea either obstructive or central seem to be frequent in patients with CH. Accompaying sleep apnea may induce CH by leading to nocturnal hypoxemia [91], and effective treatment of sleep apnea either with CPAP or dental device can also be effective to diminish the severity of clusters [9, 64, 92].

Poor sleep quality and short duration of sleep may be seen in both episodic and chronic CH [93]. During the bouts of CH, patients may suffer from transient insomnia which usually resolves after the end of the bout and may recur at the next cluster period in episodic CH [91].

Among shift-workers, episodic cluster headache incidence was found to be higher. This suggested that disturbed sleep due to the work schedule could trigger cluster headache [93, 94]. As shift-working is suspected to induce the attacks, patients with CH can be advised to have a steady daily working plan [93].

During a cluster period, elongated REM latency and diminished total percentage of REM sleep can be detected by polysomnography. Sleep-wake cycle may also be disturbed during this period (**Case 3**) [28, 95].

Fifty-two years old male patient was admitted to the headache outpatient clinic with a complaint of a severe headache on right orbitofrontal region for 3 years. Attacks mainly began at autumn and lasted for 3 to 4 weeks. Each attack has begun early in the morning and awakened him with a duration of 45 to 60 minutes. Pitosis, lacrimation, rinorrhea, and redness on the right eye convoyed the headache, which was very severe (with a visual analog score of 10). Pain was resistant to analgesics, and resting did not alleviate the headache. He did not have a history of any other diseases. Neurological examination and cranial magnetic resonance imaging were normal. He also complained of snoring and witnessed apnea.

His polysomnographic investigation recorded at the sleep center of University of Health Sciences Erenkoy Mental Health and Neurological Diseases Training and Research Hospital shows a slightly increased sleep latency. Awakenings are seen during all night, and sleep efficiency is slightly reduced. He had an attack at 05:00 AM that awakened him from sleep (shown by an arrow). Apne-hypopnea index is 6.2 (mild obstructive sleep apnea syndrome).

#### **4.4 Hypnic headache**

Hypnic headache is a rare headache disorder that mainly occurs during night sleep as well as at naps during the day [96]. Headache causes wakening and lasts for up to 4 hours without associating characteristic symptoms [81]. Attacks may occur in every stages of sleep [97, 98]. Just before and during the headache attack, elevation in arterial blood pressure has been detected in some patients. It has been hypothesized that these alterations could typify an association with sleep apnea [63]. Sleep apnea may be a trigger for the attack, and the treatment of OSAS also reduces the hypnic headaches [9, 98]. Attacks arising either from REM sleep or NonREM sleep can be documented using polysomnography (**Case 4**) [96].

Fifty-eight years old female patient was admitted to the headache outpatient clinic. She had a pressing headache on vertex which awakened her from sleep nearly every night. Attacks occured in the first half of the night with a duration of 60–120 minutes. Neither phonophobia/photofobia nor nausea/vomiting were present. Autonomic symptoms did not accompany. Pain intensity was mild (with a visual analog score of 6). She did not have any other types of headache. She also complained of snoring, and there was witnessed apnea detected by her husband. She had a history of hypertension which was under control with ramipril.

On her polysomnographic investigation recorded at the sleep center of University of Health Sciences Erenkoy Mental Health and Neurological Diseases Training and Research Hospital, we have found an elongated sleep latency and a reduced sleep efficiency. On the first half of sleep, she has awakened after first REM sleep stage (shown by an arrow on hypnogram) with a headache attack. Apnea-hypopnea index was 8.7 (mild obstructive sleep apnea syndrome). Snoring index both in REM and NonREM sleep stages were increased.

*Sleep Patterns Changes Depending on Headache Subtype and Covariates of Primary Headache… DOI: http://dx.doi.org/10.5772/intechopen.106497*

**As a conclusion**, headache prevalence is high in sleep disorders, and sleep disorders are highly seen in primary headaches. This comorbidity may induce the chronification of both of the syndromes. A detailed history of both disturbances must be taken, and clinicians should consider and behold the treatment of accompanying sleep complaints for an effective management of headache and a better quality of life.
