These Bedroom Days.

How Poor Sleep Worsens Migraines: What You Need To Know

We know from past expert interviews on sleep disruption, that it can increase our brain fog and sensitivity to pain. A lack of restorative sleep can also increase our appetite, disregulate hormones, weaken our immune system, and worsen migraine.

Let’s just start off with: why is sleep so important for the brain?

I say that sleep is when our brain rests and restores. Sleep is when basically anything that’s inflammatory sort of calms down and settles down and sleep is a time for healing

So if your body doesn’t get adequate sleep, your brain is not going to restore itself.

And for people who have migraine/headache disorders that is the key time for those hyperexcitable neurotransmitters to sort of quiet themselves down and restore

How much sleep do we really need? 7-9 hours? What can you get by with, what’s adequate?

So, the average range is 7-9 hours, but it’s a range. So some people need more, some people need less.

It’s not necessarily that we’re going to know how much each person needs and most people know ‘I feel much better when I get 10 hours or I feel better when I get 7’

I’d say the average goal is 7-9

Can you sleep too much?

You can. There are people who need more sleep, but there are also people who sleep too much because they think they need more sleep because they’re fatigued or tired.

But oversleeping can be associated with worsening migraine, but it also might be due to another underlying condition.

So I would say in my practise, it is so rare when someone doesn’t have a sleep disorder.

So I screen all my patients for sleep disorders, and I don’t honestly any problems with sleep I’m like ‘wow, that’s amazing’, because it’s so, so common.

If you look at headache disorders in general, if you have a headache disorder, especially a chronic headache disorder, you’re 17 times more likely to have an issue with sleep. So it’s really highly associated

What is the connection between sleep and migraine headache? Do we know and is it ‘does migraine cause a poor night’s sleep’ or ‘does poor night’s sleep cause migraine’?

I think a little bit of both.

So, we know that in migraine levels of melatonin, which is our sleep/wake hormone – I say melatonin is something that’s produced in our brain and in response to light and dark basically shuts on and off.

So people with migraine have lower levels of melatonin, than the general population, and also the circadian rhythm, the way the brain produces melatonin and the way it responds, is different,

which is why migraine is more common in the early morning hours, sort of like 4am to 7am, that ‘wake up’ migraine is more common because of these shifts in melatonin

We also know that people who have migraine have changes in sleep they can either be late night owls or early morning larks, and different personalities and different sleep patterns go along with migraine.

So we definitely know it’s the circadian rhythm, the way that the brain takes us through the sleep/wake cycle that’s associated with it.

Can we pinpoint the main drivers between poor sleep and the likelihood of a migraine attack?

So I wanna go back to saying the migraine brain likes consistency, so consistency with sleep is very important.

So getting consistent sleep, going to bed at the same time at night, waking up at the same time in the morning, is really important

and when that’s deviated from for example going out at night, over the weekend and then you sleep in late, that could be something that triggers migraine,

not that you shouldn’t do it, because everyone needs to go out and have fun, but just knowing that that can be a potential trigger

Also fragmented sleep. So, multiple nighttime awakenings, or being awoken at different points in the night so you can’t consolidate sleep as well.

It also tends to be a major trigger as does shift work, or jet lag, or any changes that happen to your natural sleep/wake cycle can be triggers

We’re definitely gonna touch on what we can do to overcome some of that, but I want to go back to what you mentioned, that you really evaluate all of your patients for sleep disorders and can you talk a little bit more about that and how it’s part of your process?

It’s part of my intake process, everyone gets screenings.

So I usually screen for sleep apnea with a screening called STOP-Bang, it basically looks at risk factors for sleep apnea and if someone is complaining of poor sleep and increased daytime fatigue and they screen positive on that screening then I will send them for a sleep study

The other ones we look at are really insomnia, hypersomnia which is sleeping too much and using the Epworth Sleepiness scale, trying to differentiate between sleepiness and fatigue, which you touch on also because people who have different sleep disorders score differently on those tests.

And then I just go through the basic sleep history with patients: what is their sleep routine, do they feel refreshed? Do they snore, does their partner or someone in bed say they move around a lot, do they sleepwalk? Do they have vivid dreams?

There’s so much that goes into taking a sleep history, I can go into so many more details but those are the main ones I look at.

Does the link between migraine and sleep issues similarly exist for cluster and other headache disorders, like vestibular migraine?

Because vestibular migraine is still the same pathophysiology as migraine, it still does exist, so it’s under that migraine umbrella, so absolutely.

Let’s talk a little bit more about the connection between circadian rhythm and migraine. Can you go into a bit more detail about what that connection is?

Absolutely, I first just wanna touch on what is the circadian rhythm, because I think you said the words, but what is it? So, it’s basically our bodies internal clock

And that clock is what makes you feel sleepy, makes you feel awake, and also determines how your body reacts to pain.

So when people have migraine, have cluster headache, their clock is just not working properly and it causes changes in the hormones that help control sleep and wakefulness.

So the circadian rhythm is basically our little clock in our head and it’s just not working as well in headache disorders and that’s where we have to try to help to control in our own ways this,

which is why maintaining a regular sleep schedule is important to train that clock, to know when the cues are for sleep and wake

and there’s other techniques that can also be done to get your clock running appropriately

I would love to know, what are some of those interventions that we can do besides sticking to a regular sleep/wake cycle to help better regulate our circadian clock

I think exposure to light

So what happens with melatonin is, when it’s dark outside your melatonin production changes and you’re body is told ‘ok, now I’m going to go to sleep’

so you wanna avoid bright lights leading up to when you want to go sleep, and then the opposite when you first wake up in the morning

to make your body wake up, exposure to bright light can be really helpful especially in the winters,

I find that even more using one of the light boxes to help with regulating circadian rhythm as you wake up, you put the light box on because it might not be light outside when you need to wake up,

so training your body that this is the time to wake up by exposing it to light and then turning light off when it’s time for your body to go to sleep can be really important

There’s some data for melatonin, but not for going TO sleep.

Melatonin is not a sleep supplement, it’s for helping regulate the sleep/wake cycle and for shifting the body in time to sleep at more appropriate or the times that you wanna sleep,

It’s a phase shifter, its not a sleep- it’s not putting you to sleep, but melatonin strategically can be used to help regulate

You mention that people with migraine may have lower melatonin levels in general, so if we’re restoring that to a more normal level it seems it’ll put us in a more normal pattern is that right?

Yes, there is evidence that taking 3mg of melatonin can have preventative benefits for migraine likely due to low melatonin levels,

but there are different ways to use melatonin based on the underlying sleep issue, but as a general recommendation, there is evidence for using melatonin

How far before bedtime would you take it?

About 30 minutes before bedtime

Really important though, I think a lot of people take melatonin and then they go watch TV or they go in bright lights, so light inactivates melatonin, because that’s what it’s supposed to do.

So if you take a melatonin supplement and then go watch TV or out in bright lights, it’s not going to work.

So it’s still the same, if you’re taking a supplement you need to not expose yourself to bright lights after taking it.

A normal circadian rhythm has always been preached as good for human health, however, some of us are night owls to avoid the painful light of the sun. As long as we still get enough quality sleep, does being nocturnal because of migraine honestly ruin our health in other mysterious ways?

It doesn’t matter what time you go to sleep, that’s a society driven concept.

So everyone’s body has their own clock and what time your body is set to be sleepy and go to sleep is going to be different for everyone

Go to bed when your body is ready to go to bed and wake up when your body is ready to wake up

For those who are really struggling with waking up too early and often in pain, do you have any other suggestions or reasons why that might be happening and how to mitigate that?

So, like I said before, that the chemicals that are involved with sleep are dysregulated especially during those early morning hours

I would say prevention here really is the best form of treatment, is that if we can actually tone down migraine overall to make migraine attacks less likely to happen, then your body is less likely to have a migraine attack in that portion of the night

Also if you’re someone who is having a wake up attack, oral meds/rescue meds aren’t likely to be effective, because the attack has been brewing during the night

This is where I recommend reaching for an injectable medication, or a nasal spray if you don’t like to inject,

but really looking for ‘I’ve woken up with this, how can I make it go away the fastest’ would be sort of the best part of the treatment plan really prevention overall,

just trying to reduce the overall migraine frequency and make sure that the sleep cycle is regulated is the best thing to prevent that from happening

and again there are many sleep disorders that go into it that have an association with early morning awakenings and assessing for those as well as other comorbid disorders that also tend to dysregulate sleep during those early morning hours is something that you and your doctor should talk about

Do you recommend naps?

I love a good nap, but naps are not a good idea

So naps tend to mess up the natural circadian rhythm and tend to then interfere with nighttime sleep.

If somebody really needs a nap if they’re super tired, ok, the nap should be 30 mins or less, a really short nap so your body doesn’t go into deep sleep and is just restorative,

but overall I find that napping does worsen migraine, just because again it’s changing your the way that your body is reacting to a light source and you’re sleeping when you should be awake

Do certain migraine and headache meds affect sleep?

There are different preventative meds that can impact sleep.

Things in the beta blocker class might have some interference with the sleep/wake cycle, not all of them again it’s really dependent

Some of the meds that are more stimulating like some of the SNRI class of meds can interfere with sleep, but it also depends on timing then. We want to time the meds so they don’t.

Also on the opposite of interfering with sleep, there are meds that also cause excessive drowsiness that we use for migraine that even though people are sleeping more, they’re overly tired, so that is also affecting the sleep cycle on the opposite end by causing too much sleep

Are there certain migraine meds that might help with sleep?

None of the meds necessarily help restore someone to a natural pattern of sleep.

There are other strategies to do that, but most of the meds make people tired, which or sleep, which in turn helps them to sleep.

So things like tricyclic antidepressant class, amitriptyline is common, that causes fatigue as a side effect and therefore can help with sleep

but it’s not directly helping with the issues with sleep, just causing fatigue as a side effect

but I’m okay with that, I feel like what’s the chicken and what’s the egg, is it poor sleep triggering migraine, or migraine triggering poor sleep?

Wherever I can intervene to correct it, great. Even if the med makes you tired if that’s helping you sleep which helps migraine, great.

Brain fog is common after a poor nights sleep and during migraine attack – is the same mechanism at play in our brain?

We use sleep to consolidate memory, sleep is a time when your brain is resting, it’s recovering.

It’s taking what you did for the day and then banking some of those memories away, clearing some other ones out and with migraine your brain is firing pain signals very very frequently, that is also interfering with your ability to think.

You put not sleeping on top of that? I think that’s when someone comes in and they say they’re having memory problems, I’m like ‘you have migraine and you don’t sleep. Let’s work on those and I bet your memory and concentration and brain fog will improve and it does’

Let’s talk more about sleep disorders and migraine. We’ve talked about sleep apnoea and insomnia, can you talk about those a little more and any other most common sleep disorders?

I will start with insomnia because that’s the one I see the most, but when we say insomnia it’s a very broad term,

there’s different types of insomnia,

there’s sleep initiation, meaning trouble falling asleep

There’s sleep maintenance insomnia which is difficulty staying asleep

and there’s a combination of both, but they’re approached differently because falling asleep and staying asleep are mechanistically a little bit different in the brain,

and when you’re going and looking at evaluating insomnia it’s really important to say ok where is the problem and then how do we fix it

so the only way to truly fix insomnia is through a method called cognitive behavioural therapy for insomnia, CBTI, which is different from regular CBT,

this is not a talking experience - I look at it as you’re retraining your brain to sleep: what happens in insomnia is the brain no longer understands how to sleep and so CBTI retrains it.

One of the biggest pillars is sleep restriction and sleep consolidation so basically training your brain to consolidate your sleep and there’s various methods to do this, there are certain practitioners who specialise in it,

but going through the different phases and the different parts of CBTI

one of them is sleep restriction, there’s stimulus control, relaxation techniques, there’s different parts of it that really, for long term success in studies, is really the only way to fix the underlying problem of insomnia.

Meds can help but it is not retraining and basically changing your brain back to how it should be sleeping.

There’s apps for it, google it, there’s, especially now in the era of having tele-medicine and video and all these resources available, I feel like you don’t necessarily need to go to someone specifically there are dedicated programs you can do at home,

it’s again sticking with it and consistency I feel like it’s worth it

What about other sleep disorders that are commonly comorbid with migraine?

We talked about sleep apnoea.

So I say that if you snore, if you wake up with dry mouth, if you are really sleep during the day those could be signs of sleep apnoea

and again wake up headache, wake up headache is a common sign of migraine in general but also sleep apnoea and we know sleep apnoea worsens migraine,

so if there’s any sleep apnoea, even if someone gets a test and it says ‘mild sleep apnoea’ we are treating that,

we need to treat the sleep apnoea, so again a very comorbid sleep disorder but then some of the ones we don’t talk about as much

Hypersomnia, or being excessively sleepy and needing more sleep, so that’s the people with the chronic fatigue, very just, again, the difference between sleepiness fatigue but basically needing more sleep, needing too much sleep

Then we have the parasomnias, which are things like sleepwalking or nightmares, having very vivid dreams,

again disturbances in the REM/non-REM sleep cycles can definitely happen more with migraine, so if that’s happening that’s a good time to get sleep study and try to intervene on it.

RLS, restless leg syndrome, is a very common comorbid condition with migraine.

If you feel like your legs are restless or your having any sort of trouble staying still when you’re in bed, you should be looking for RLS,

so even if someone doesn’t complain of that, if somebody is having poor sleep, I always recommend looking at iron levels and ferritin levels because we know that lower ferritin, which is a marker of iron stores, is lower in people who have sleep disorders, especially RLS, and iron supplementation alone can be helpful

The last one I’ll touch on is bruxism which is sleep related teeth grinding, a lot of times I’ll say how much does it impact migraine, we say it’s based on the degree.

We know that nerves that come from that area do feed back and can contribute and precipitate migraine, so there are reasons to treat sleep bruxism aside from just tooth and enamel wear, but it can be a precipitant of migraine attack

Let’s talk about sleep hygiene, highlight some of the most important aspects for those of us with migraine, especially since we know sleep fragmentation and deviation from typical sleep are triggers for an attack.

So I wanna touch on avoiding screens and bright light before bed

Having a nighttime routine, sort of like a calm down, I look at it like ‘my brain has been overstimulated all day, what is a good way to calm it down and get it ready for sleep’

so taking a bath/shower/having a cup of tea/doing a nighttime relaxing ritual/reading a book under dim light can be helpful leading up to sleep, just to tell the brain it’s a signal, it’s a time for you to start winding down to go to sleepiness

and making sure the bedroom is only used for sleep and sex, it shouldn’t be used as a place that you hang out in all day, you shouldn’t be sitting and working in bed and being in bed doing other things it really, the brain needs to know ‘this is the place that I go to to sleep and nothing else’

[A migraine patient] often wakes with neck pain, which can be associated with migraine attacks – can you recommend a pillow?

Something in the middle of the night, our positioning, whether it’s the migraine generator that is happening that then triggers the neck pain,

but a pillow that is supportive and that at least is supportive as you can get depending on if you’re a side sleeper/back sleeper/stomach sleeper, I find the ones that cradle the neck tend to be a little bit better

Can migraine be refractory to treatment with a pre-existing sleep disorder, in other words, do we require improvement in our sleep disorder to improve our migraine condition?

So yes and no.

I will say that one of the most overlooked in my opinion things in chronic intractable migraine is not looking for a sleep disorder, because we know that if we don’t treat the sleep disorder and the sleep part of it it is really hard for chronic migraine to improve,

so every patient that’s got intractable or who really is not getting better on standard therapies, we have to look at the sleep,

not that that’s 100% it and that fixing it is going to change everything, but it’s a missing part of so many evaluations because I think it takes a lot of time to discuss and you have to go through different parts of sleep history and really laying it all out there,

but I feel like its super, super important, and if you aren’t getting better on your current treatments, please talk to your doctor about your sleep and sleep pattern,

keeping a sleep log/sleep journal is the best first step, basically there’s different ways to do it online there’s a ton of resources out there

and showing just how to keep a very basic sleep diary there’s lots of fitness apps, wearables now that do that too, but you’d be surprised, if you don’t think that there’s an issue with sleep when we look into it, sometimes it really is right there in front of us

Throughout our discussion we’ve talked about interventions that help with issues with sleep and hopefully also with migraine management. You’ve mentioned CBTI, are there other non-drug interventions that help or can you break CBTI down just a little more?

a lot of the non-drug interventions are actually incorporated under CBTI: relaxation, mindfulness, meditation, yoga, practices that are common both cognitively and can also create behavioural change can be helpful

doing these relaxation therapies can be extremely helpful. I have some patients who put on a guided meditation every night before bed find that to be extremely helpful

Let’s move to more meds for sleep disorders, you’ve talked about melatonin, lemme walk through some of the common ones and get your thoughts

3mg melatonin is what’s recommended for a migraine prevention dose, but melatonin in general is really dosed based on why you’re using it

so actually, if you’re using melatonin for a phase shift disorder, or jet lag disorder, different ones that include changing the timing of sleep it’s going to be a much lower dose than that, usually 0.5mg and it’s spaced differently

Melatonin is not a one size fits all, and just because it’s over the counter supplement doesn’t mean it shouldn’t be monitored by a doctor

dosing is extremely important, more is not better when it comes to melatonin

Can seniors take melatonin with their doctors oversight?

Doctor’s oversight and using it appropriately yes, but again, it’s not a sleep aid

Melatonin is not used to cure insomnia or to help someone be sleepy and sleep, it’s used to fix incorrect circadian rhythm disorders and those associated issues

Magnesium, how much and what kind?

So for migraine in general I recommend magnesium glycinate, becaue it’s well absorbed and doesn’t upset the stomach at a dose of 400-600mg a day

but if you have other magnesium forms it’s totally fine as well, that’s the one I typically recommend

Benadryl can be part of a migraine cocktail sometimes to abort an attack

Benadryl’s a double edged sword, antishistamine so by nature can make you tired.

Antihistamine properties can also help with migraine but it can be habit forming in the sense that it becomes a sleep dependency, like in order to sleep you need to take benadryl

that med, and other ones too, actually disrupts the different stages of sleep,

it’s basically making you tired, it’s not correctly putting your body into the right parts of sleep

so I’ll say benadryl, short term fine, long term not a solution

Does the same apply for other sleeping pills, any you recommend for short term use?

It depends, there are sleep aids that are FD approved for sleep

there are some that are for sleep initiation insomnia, and then there’s some for sleep maintenance insomnia, so figuring out and knowing what you’re treating

also again, meds can be helpful short term and there are rare people who need them longer term, going back to CBTI something that should be done even when taking meds

but this is something where I think sleep doctors/physicians can really help because there’s now so many meds out there and it really just depends on what the exact issue is with your sleep

What about HRT for women and perimenopause and menopause, is that effective for sleep?

So perimenopause, menopause, I feel like the sleep wake cycle circadian rhythm all that sort of just goes crazy

if you’re a candidate for HRT - and there are comorbidities where you might not be - I have definitely found that HRT can help with the sleep disruptions that happen from hormonal changes and hormonal fluctuations

any other final thoughts about sleep and migraine?

The take home point is, sleep should be discussed with every time you’re seeing a new headache doctor

and bringing up sleep is something that is crucial in that headache history

there are a lot of resources out there that can also help with insomnia, with sleep, which is getting more information about sleep, so I just want to encourage everyone to talk about it

FREE RUNNING (sleep/wake 1-2h later daily)

pros:

-better sleep quality, mood, and more energy overall

-all usual activities doable, just depends on timing

-feels more natural to me

cons:

-inconsistent sleep quality

-pushing for 1 day means needing 2+ days recovery time

-im gonna die early

-less predictable schedule, affected by mood and daylight hours and season

-loneliness and isolation

-not being able to consistently do anything without pushing sometimes

ENTRAINMENT (extra light during day + avoid light in evening)

pros:

-predictable schedule for 1-3 months

-being able to commit to things

-having a social life

-routine

cons:

-losing entrainment feels terrible

-entrainment feels terrible (headaches, sore eyes, dry eyes, depression, small window during the day for productivity and hobbies until i have to avoid light, no going out/parties at all, everything takes more energy, irritability, sorer body when waking up, drier skin, more dysregulated poops)

-is this worth it 💀💀💀