About 15% of the world’s population experiences at least one migraine attack every year: severe, by other intense symptoms such as nausea, extreme sensitivity to light or noise, and/or visual or sensory distortions known as auras.
For many migraine sufferers, sleep issues are also part of the mix and can even be a predictor of increasing frequency. Read on for an overview of the most common occurring sleep disorders that can accompany migraine headaches, as well as recommendations to help alleviate suffering.
Episodic versus chronic migraine
Given both the prevalence of migraine headaches and the severity of symptoms, migraine is ranked as the second leading cause of disability worldwide. It’s also a condition that’s three times as likely in women than in men and peaks in the mid-to-late-thirties.
Migraine attacks, which can last up to 72 hours before subsiding, fall into one of two categories: episodic and chronic. Episodic migraine attacks, which occur less than 15 days a month, are further categorized as high-frequency episodic migraine if they occur between eight and 14 days a month. If they continue to increase in frequency (to at least 15 days a month), they’re classified as chronic, a condition that affects about 1 to 2% of the population.
“Clinically, we’re always on the lookout for those people who are going to be converting from episodic to chronic and trying to intervene before that happens,” says Dr. Angeliki Vgontzas, a neurologist and headache specialist at Brigham and Women’s Hospital and assistant professor of neurology at Harvard Medical School. The goal is to “keep them in the episodic category, where they’re not going to be experiencing as much disability.”
Sleep issues most associated with migraines
A higher percentage of people with chronic migraine report sleep problems than those with episodic migraine, Vgontzas notes. She characterizes it as dose-response relationship: “The worse your migraine is, the more likely you are to report having sleep problems.”
It’s also possible that sleep issues may be an indicator of “migraine chronification,” in which the number of monthly headache days increases to 15 or more.
There are a few sleep disorders commonly associated with migraine:
Insomnia
Among migraine sufferers, insomnia is the most commonly reported sleep disorder. Interestingly, in an analysis of patients with chronic migraine, treating insomnia with cognitive behavioral therapy for insomnia (CBT-I) also decreased their monthly headache frequency, resulting in about six fewer headache days.
Although there haven’t been similar studies of episodic migraine sufferers, the results “showed how powerful it was to improve someone’s sleep and improve their headache frequency,” says Vgontzas, who wasn’t involved in the study. “That kind of reduction is really comparable to a lot of the medications that we use specifically for migraine,” she points out.
Restless Legs Syndrome
People who experience restless legs syndrome (RLS) are more likely to experience migraine than those without this syndrome. Although the relationship goes both ways, having RLS is thought to have a greater impact on migraine than the other way around. “If you have migraine, you’re four times more likely to have a diagnosis of restless legs syndrome than if you don’t,” Vgontzas says.
Bruxism
Teeth-clenching or grinding, known as bruxism, as well as temporomandibular joint dysfunction (TJD), which causes pain in the jaw and surrounding muscles, may also occur in migraine patients. Having both bruxism and TJD has been shown to greatly increase the risk of chronic migraine and increases the risk for episodic migraine as well.
How episodic migraine can affect sleep
In a study published in 2021, Vgontzas examined whether poor sleep quality predicted subsequent migraine attacks.
Participants tracked their headaches over a six-week period. During the study timeframe, the participants averaged eight headache days a month. The data showed that those who reported poor sleep were 22% more likely to have a headache on any given day during that period. However, “poor sleep on any given day was not associated with an immediate headache the next day,” Vgontzas points out. “It was just at some point over the next six weeks.”
The risk was even greater for participants who also reported higher stress levels: They were 31% more likely to have a headache during the six-week timeframe.
The study was prospective, Vgontzas points out; participants recorded their sleep and headache information without knowing whether they would have a migraine attack the next day. However, when she sees patients in clinic, their retrospective observations about sleep and migraine often tell a different story.
“One of the most commonly reported triggers of migraine is changes in sleep,” she says. “People tell us they don’t sleep enough, or they slept too much, or they had some change in their sleep quality.”
“[That’s] pretty common in the research on migraine triggers. There’s kind of a mismatch between what patients are telling us in clinic retrospectively and what the studies are finding prospectively through diaries.”
That said, “for some individuals, there probably is a very strong relationship between the two,” she notes. For patients who see a link between how they sleep and subsequent migraine attacks, she recommends they complete daily diaries and track their headaches prospectively to get a better sense of whether that’s the case.
Addressing sleep as part of addressing migraine
For people with sleep issues and migraines, “the overall recommendation is to get your sleep assessed and get your headaches assessed,” Vgontzas says. She recommends against self-treatment, such as melatonin, which can delay people from getting more effective, evidence-based treatments.
Those treatments include a number of preventive medications, as well as Botox, which was FDA-approved for chronic migraine in 2010. “For patients with chronic migraine, it can be very effective,” Vgontzas said, but it can take several sessions to reduce migraine frequency and needs to be taken on an ongoing basis.
While there isn’t a cure for migraine, it’s treatable for most patients, she adds. “My clinical experience is that almost every patient with migraine does improve.”
