Abstract
Although sleep problems are a common complaint in migraine patients, the role of sleep habits and hygiene as triggering factors of head pain attacks has been poorly analyzed. The aim of this study was to evaluate the effect of modifying bad sleep habits across several headache parameters. Based on our previous study, we selected 70/164 migraineurs (42.7%) with poor sleep hygiene and randomly assigned them to two groups: group A migraineurs, who were instructed to follow directions to improve sleep hygiene; and group B migraineurs who were not given instructions on improving sleep hygiene. Mean duration and frequency of migraine attacks were significantly reduced at follow-up in group A, while group B showed only an insignificant initial reduction. No differences were found in the severity of migraine attacks that seemed related to a higher prevalence of nocturnal symptoms such as bedtime struggles, hypnic jerks, nightmares, and restless sleep. Our study is an alternative approach to the treatment of migraine, i.e. treatment through a simple modification of sleep behavior without recurring to pharmacological treatment.
Keywords
Experimental and clinical studies suggest a link between sleep and headache: sleep state has been related to the occurrence of some headache syndromes, and headache patients are more prone to sleep disorders (1). Further, inadequate sleep duration or bad sleep quality are common triggering factors for headache (2).
Both child and adult headache patients complain of sleep problems such as difficulties at the onset of sleep, wakening, nocturnal symptoms and more awakening symptoms (3 –5). However, the complex mechanism underlying this association is still poorly understood. In several cases of headache in adults the diagnosis has been changed after a polysomnographic study and the treatment of the underlying clinical condition improved the headache greatly (6).
In children, as well as in adults, the role of sleep habits and hygiene as triggering factors of head pain attacks is a new focus of interest, never analyzed in a treatment perspective of childhood and adolescence migraine. The possible influence of sleep habits and hygiene on childhood and adolescence headache attacks has been poorly analyzed (7).
Sleep hygiene has been defined as the conditions and practices that promote continuous and effective sleep: these include regularity of bedtime and arising time; conformity of the time spent in bed with the time necessary for sustained and individually adequate sleep (i.e. the total sleep time sufficient to prevent sleepiness when awake); restriction of beverages, foods, and compounds (which tend to disrupt sleep) before bedtime; and the employment of exercise, nutrition, and environmental factors that enhance, not disturb, restful sleep.
Sleep hygiene rules should lead to “good sleep quality”. The definition of sleep quality in children has been a matter of controversy. We had to rely on the child's self-report or on the parents' information on restless sleep and difficulty of awakening in the morning. A misperception of bad sleep quality could lead to a diagnosis of headache or migraine, since the child's discomfort or pain could be referred as head pain and not attributed to poor sleep quality. Furthermore, in children and adolescents there is an increasing tendency to follow bad sleep habits for social reasons, and to achieve a sleep phase delay syndrome (8).
Because of the close relationship between headache and sleep, we hypothesize that several headache children could have inadequate sleep hygiene. They could therefore be more prone to head pain attacks; there could even be an exacerbation of frequency, duration, and intensity of pain attacks. The aim of this study was to evaluate the effect of the modification of bad sleep habits on several headache parameters.
Method
In our previous study (5) we administered a 45 sleep items questionnaire to a sample of 283 headache subjects (164 with migraine and 119 with tension-type headache). Based on these results, we selected the migraine group, i.e., the more “sleep disturbed one”, in order to verify the presence of bad sleep habits or altered sleep hygiene.
We considered the following items for defining poor sleep hygiene: bedtime later than 11 p.m.; wake-up time later than 8 a.m.; nap during daytime; irregular schedule (bedtime and wake-up time varying by more than 1 h on school days); cola, tea, coffee, chocolate, or similar substances late in the afternoon or in the evening; the need to drink fluids or take drugs to facilitate sleep.
The sleep hygiene items were related to the following parameters: headache frequency, severity, and duration of the headache attacks. Selected children and their parents were then instructed to follow sleep hygiene guidelines and to fill out a sleep log daily to monitor their sleep.
Diagnosis of headache was defined through a structured questionnaire according to the International Headache Society (IHS) criteria (1988). Migraine children underwent routine diagnostic procedures, filled out a headache diary, and were initially compared to the control group in order to define groups based on the presence of at least two of the aforementioned criteria for defining poor sleep hygiene. After defining the poor sleep hygiene migraine subjects, the sample was randomly split into two groups: group A—instructed to follow guidelines towards improving sleep hygiene; group B—not instructed on improvement of sleep hygiene.
The patients and their parents were controlled once a week to enforce the guidelines, to control the sleep behavior modifications, and to enhance compliance. The possible influence of the changing of sleep habits across several headache parameters (duration, frequency, and severity) has been evaluated after two follow-up periods (3 and 6 months).
Subjects
The clinical sample comprised 164 migraine patients (89M and 75F; mean age 10.3 years; s.d. + 1.7 years; range 5.0–14.3 years). This sample was compared with the control sample (893 healthy children: 433M, 460F; mean age 10.6 years; s.d. +1.3 years; range 5.5–14.7 years).
Based on the presence of at least two criteria for defining poor sleep hygiene, 70 migraineurs (42.7%) were selected and randomly assigned to group A or B (see method): the A sample (20M, 15F; mean age 9.3 years; s.d. +1.3 years); the B sample (18M; 17F; mean age 10.1 years; s.d. +1.6 years).
None of the patients entering the follow-up study was treated pharmacologically.
Results
The 70 migraine children selected showed several differences versus controls in sleep habits: falling asleep later (falling asleep >11 p.m.: 16% vs 7%; p < 0.001), waking up later (wake-up time >8.00 a.m.: 3.5% vs 0.2%; p <0.0001), nap during daytime (7.4% vs 3.3%; p < 0.005); reduction of night sleep duration (558′ vs 565′; p < 0.05), irregular schedule: bedtime (10.6% vs 5.8% p < 0.05) and waking up time (9.2% vs 1.7%; p < 0,0001) varies by more than an hour on school days.
After application of the sleep hygiene guidelines, we found differences between both groups in the case of several headache parameters. Mean duration of migraine attacks was significantly reduced at follow-up in group A (at first observation 234′; at 3 months 78′, and at 6 months 65′), while group B showed an initial reduction but not a significant one (Table 1).
Mean duration of migraine attacks.
The frequency of migraine attacks also showed an improvement: at the first observation the prevalence of group A subjects with more than one attack per week was 35%; at 3 months 15%, and at 6 months 11%. In group B the percentage did not change significantly (at first observation 42%; at 3 months 37%, and at 6 months 33%).
No differences were found for the severity of migraine attacks; the prevalence of subjects with mild or high severity of the attacks did not change significantly in any of the groups at follow-up. The prevalence of high severity attacks in group A was 48% at the first observation, 50% at 3 months, and 49% at 6 months; in group B this was 54% at the first observation, 52% at 3 months, and 46% at 6 months.
Since the attack severity did not seem to be influenced by bad sleep habits, we evaluated the presence of other sleep problems that could be related to this migraine variable. We found a higher prevalence of nocturnal symptoms in these subjects in both the A and B samples: bedtime struggles (42.55% vs 25.87% Chi square 5.15; p < 0.05), hypnic jerks (21.28% vs 7.96% Chi square 7.20; p < 0.01), nightmares (8.51% vs 2.49% Chi square 3.95; p < 0.05), and restless sleep (34.04% vs 17.41% Chi square 6.45; p < 0.05).
Discussion
Our study is an attempt to improve the situation of the migraine patient by correcting inappropriate sleep behavior. Through simple modification of behavior we could obtain an improvement in migraine attacks without resorting to pharmacological treatment. Modifying sleep habits following the sleep hygiene guidelines could be considered as tantamount to behavioral treatment for sleep. This modifies the way in which the child responds to stress and external stimuli in the sense that the child seems to be more protected from migraine attacks: Could sleep be a sort of “guardian” of migraine?
The finding of a strong association between bad sleep habits and migraine was the starting point for our enlarging the analysis to focus on the possible role of better sleep habits in relieving migraine attacks. It did not solve the problem, but the improvement seemed to be consistent and long-lasting.
The relationship between sleep disturbance and head pain attacks raises the question about the role of common physiological, psychological, and environmental factors. The nature of this relationship is unknown. There could be a vicious circle of mutual reinforcement of sleep and migraine. Based on our data, getting good sleep could mean a lower frequency and shorter duration of migraine attacks. The severity of the attacks, however, seemed to be independent of bad sleep habits, and more related to the presence of sleep disorders such as hypnic jerks, nightmares, or restless sleep. We therefore hypothesize that the frequency of migraine attacks and their duration are related to modification of the circadian rhythm, while the severity is more related to the alteration of the structure of sleep.
Any comprehensive approach to the diagnosis and treatment of childhood and adolescence migraine cannot ignore these facts. The role of the modification of bad sleep habits in relieving factors of migraine frequency and duration has been well identified in our study and strongly supports the importance of closer examinations in multilevel treatment of migraine.
The relationships between sleep-state and physical and mental health in children and adolescents are only beginning to be explored, and the informed clinician must be concerned about sleep-state organization in all children who present with physical or psychological disorders.