**4. Effects of headache on sleep**

#### **4.1 Migraine**

Migraine is one of the most disabling primary headache with a pulsating quality and moderate to severe intensity, mainly located unilaterally and lasting for 4 to 72 hours. It may be aggrevated with physical activity and nausea and/or phonophobia, and photophobia may accompany [81]. Migraneurs have higher scores of Pittsburg Sleep Quality Index (PSQI) showing a poor sleep quality [13]. Frequency of attacks were found to be related with decrease in sleep quality, and prevalance of poor sleeper is high in migraine [70]. Poor sleep quality may be in association with chronic migraine, and patients with chronic migraine may have more sleep disorders comparing episodic migraine [8, 54]. Bertisch et al have investigated sleep efficiency of patients with episodic migraine with actigraphy. They have found a relation with poor sleep efficiency characterized by fragmentations during sleep and a migraine attack on the following day. No temporal association was found between poor sleep quality and shorter duration of sleep. They have concluded that fregmantations rather than duration of sleep have a role in inducing frequent attacks in episodic migraine [82]. On the other hand, some studies have not found an association between headache and fregmantations in sleep during night [25, 83].

Obesity is a common risk for both migraine and OSAS, and migraineous patients may be sensitive to hypoxemia which is also associated with OSAS headache [4]. Comorbidity of OSAS increases the frequency of migraine attacks, and chronicity of migraine can be due to sleep apnea [65]. Morning headache attacks in migraineurs can be associated with sleep apne or snoring [84].

The polysomnographic features of migraneurs may show alterations compared to nonheadache population. Sleep latency is found to be normal or longer, and the percentage of NonREM1 sleep is slightly higher, while NonREM3 sleep stage is decreased interictally [40, 84]. The latency of rapid eye movement (REM) sleep may be longer. The total amount of REM sleep may decrease, and sleep efficiency may also be low [13, 84]. In the microstructure of sleep in migraneous patients, rate of CAP and amount of CAP cycles and arousal index in REM and NonREM sleep stages may be low [28, 40], or arousals may be frequent especially in patients with aura [38].

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

Pediatric patients with chronic migraine or migraine attacks with severe intensity may have short duration of sleep with an increased sleep latency as well as decreased percentages of NonREM 3 and REM sleep stages [84].

Migraneous patients have more complaints of insomnia [85], and the rate increases with the comorbidity of psychiatric diseases such as anxiey disorder and/or depression [86]. Sleep may be fragmentated cause of headache. The patients may also complain of symptoms of insomnia previous night before a morning headache attack with a decrease in the amount of NonREM3 sleep stage [83].

Treatment of associated sleep disorder has beneficial effects on migraine therapy. It has been shown that if the sleep disorder is treated, accompanying migraine may turn from chronic form to episodic one (**Case 1**) [9, 13, 87].

Thirty years old male patient was a shift-worker in a factory. He was admitted to the headache outpatient clinic. Since childhood, he had a pulsatile and throbbing unilateral headache mainly on the right orbitotemporal side. Localization might change at different attacks. Pain duration wass 8 to 10 hours, and pain frequency has increased after he began to work as a shift-worker [>15 days/month]. Pain intensity was severe (with a visual analog score of 10). Phonophobia, photofobia, and nausea and sometimes vomiting accompanied the headache, and pain was elevating by climbing stairs or walking. There was no preceeding aura. Stress and inadequate sleep triggered the pain, while pain alleviated if the patient could sleep during the attack. His mother had a diagnosis of migraine without aura.

As he also complained of snoring without any witnessed apnea and paresthesia on his legs when he lied down for sleep which alleviates as he got up and walked around, he underwent a polysomnographic investigation at the sleep center of University of Health Sciences Erenkoy Mental Health and Neurological Diseases Training and Research Hospital.

On his polysomnographic investigation, we have detected slightly reduced sleep efficiency. NonREM1 percentage was high, while NonREM3 and REM sleep percentages were found to be low during all night. Arousal index in NonREM sleep stages and snoring index both in REM and nonREM sleep stages were increased. Apne-hypopnea index was 2.1 (not pointing out an obstructive sleep apnea syndrome).

Hypnogram of the patient that has been recorded by polysomnography. Gray horizantal lines show NonREM sleep stages ( N1, N2, and N3) and wakefullness [W], red lines show REM sleep stage [R], and green vertical lines show arousals.

#### **4.2 Tension-type headache**

Tension-type headache is the most common primary headache, mainly bilaterally with a pressing or tightening quality and a mild to moderate intensity. The duration may be 30 minutes to 7 days. Routine physical activity does not worsen the pain.

Though photophobia or phonophobia may be present, nausea does not accompany [81]. Several sleep disturbances like hypersomnia, insomnia, or circadian sleep-wake disorders may accompany TTH [8, 88]. The decrease in sleep quantity is one of the most important triggers, and many of the patients with TTH report unsatisfied sleep [8].

Eppworth sleepiness scores and PSQ scores are higher in TTH patients indicating poor sleep quality and daytime sleepiness [83]. Decreased sleep quality is in relation with higher intension of headache attacks and can be a factor for the chronification of TTH [57, 89]. Patients with sleep disorders tend to have lower threshold of pain [83]. Accompanying depression may contribute to decrease the pain treshold [90].

On polysomnographic investigation, NonREM 1 [N1] latency was found to be decreased with an increase in NonREM 3 [N3] sleep, while the structure of REM (both the latency and total amount) was not effected. Decrease in total sleep time and poor sleep efficiency due to increased sleep fregmentation with arousals may also be observed [83].

Sleep-related movements and restless legs syndrome can also accompany TTH [8, 73]. Association with OSAS is not clear, but if OSAS is diagnosed, it must be treated properly [7, 9]. In children, a relation between TTH and bruxism was also found (**Case 2**) [84].

Twenty-three years old female student was admitted to the headache outpatient clinic with a bilateral headache on frontal regions with a pressing quality since 3 years. Pain duration was 3 to 72 hours with a pain frequency more than 15 days in a month. She had no phonophobia or photophobia. Nausea might be present. Short duration of sleep and working with computer for long hours triggered the attacks. Pain intensity was moderate (with a visual analogue score of 6). As she complained of difficulty in maintaining sleep more than 3 times a week and daily sleepiness and snoring, she underwent a polysomnographic investigation at the sleep center of University of Health Sciences Erenkoy Mental Health and Neurological Diseases Training and Research Hospital

On her polysomnographic test, we have found elongation of sleep latency with a reduced sleep efficiency. NonREM1 and NonREM3 percentages are slightly increased. Frequent awakenings and short arousals are observed in the microstructure. Abnormal sleep-related breathing events were not detected.

Hypnogram of the patient that has been recorded by polysomnography. Gray horizantal lines show NonREM sleep stages (N1, N2, and N3) and wakefullness (W), red lines show REM sleep stage (R), and green vertical lines show arousals.
