Migraines and Sleep
Migraines are extraordinarily common, affecting over one billion people worldwide. Nearly 1 in 4 U.S. households have at least one person who regularly experiences migraines.
Migraines–and most chronic headache disorders–have been proven to be comorbid with sleep disorders. If you experience migraines, you are between 2 and 8 times more likely to experience sleep disorders than those who don’t. What’s more, sleep disorders often exacerbate the symptoms of migraines and may increase their frequency. If left unaddressed, this can create a vicious cycle in which the two conditions feed off and trigger one another.
However, there are many methods–both medical and non-medical–for people who experience migraines to stop that cycle. In this article, we will delve into the subject of migraines, explaining what migraines actually are, how they interact with sleep, and what you can do to improve your quality of life if you are living with migraines and/or sleep disorders.
What are Migraines?
Migraines are generally experienced as a severe throbbing pain on one side of the head (though sometimes the pain is felt on both sides of the head.) They are often accompanied by nausea, vomiting, and severe stimulus sensitivity, especially to light and sound.
A person can develop migraines at any point in life, but most frequently, migraine sufferers start to experience them in childhood, adolescence, or early adulthood. Migraines are very common, with approximately 39 million migraine sufferers in the US. They are particularly common among women: of those 39 million people with migraines, 28 million are women. 18% of all US women suffer from migraines, as opposed to 6% of men.
Migraines can last for hours to days and can come in quick succession of one another. The severity of symptoms varies from person to person, but in some cases, they can completely disrupt the activities of everyday life. They can render a person unable to work, interact with others, or even function on a basic level.
Like many other health conditions, migraines are often profoundly influenced by sleep, and in some people, sleep is profoundly affected by migraines. Migraines can cause so much pain that a person is unable to sleep, or can exhaust them so much that it causes them to sleep more than usual. However, these sorts of sleep disturbances are also a trigger for migraines. This can create a “chicken and egg” scenario, wherein you don’t know if the sleep issue is causing the migraine, or the migraine is causing the sleep issue.
What Causes Migraines?
Migraines have a long history. They were mentioned in the medical documents of the Egyptians, as early as 1200 BCE, making them one of the oldest recorded diseases of all time. Initially, like many other conditions, they were stigmatized and considered a spiritual or moral defect. Once they were recognized as a medical disorder, there were many theories about what caused them. Some theorized that the cause had to do with an injured connection between the stomach and the brain, due to the combination of neurological and gastrological symptoms. During the first half of the 20th century, Dr. Harold G. Wolff laid the groundwork for a vascular theory of migraines, proposing that they are caused by dilation and constriction of the blood vessels in the head.
That theory has recently been superseded by a genetic, neurogenic theory of migraines. It is still not fully known exactly what causes migraines. However, they are now believed to be a neurological disorder involving changes in neural pathways and brain chemicals. Migraines have been linked to changes in the brainstem and how it interacts with the trigeminal nerve (the major pain center in the brain), as well as other neurotransmitters (such as calcitonin gene-related peptide, or CGRP) and brain chemicals (such as serotonin). It has also been proven that migraines are hereditary.
In people who are predisposed to migraines, they can occur with no external cause. However, they can also be triggered by environmental factors.
Common triggers for people who experience migraines include:
- Hormonal changes in women, such as menstruation, menopause, pregnancy, and/or the use of hormonal contraceptives and hormone replacement therapy
- Sensory stimuli, such as bright lights, strong smells, and loud sounds
- Intense physical activity
- Changes in weather or barometric pressure
- Certain foods (including aged cheeses and salty food) and food additives (including aspartame and MSG).
- Changes in eating habits, such as skipping meals or fasting
- Certain medications (including vasodilators, such as nitroglycerin)
As mentioned above, one of the most common triggers for migraines is sleep disturbance, including getting too much sleep, getting too little sleep, or environmental disruptions like jet lag.
Types of Headaches
Not all headaches are the same. In fact, there are over 300 different types of headaches. What’s more, only about 10 percent of headaches have a known cause. However, all headaches fall into one of two categories: primary headaches, and secondary headaches. Primary headaches and secondary headaches have different characteristics and different effects on sleep.
Primary Headaches: Primary headaches are the result of problems with the pain-sensitive structures in your head. They are not a symptom of a separate, underlying disease or condition. There are four common types of primary headache:
Also referred to as a “common migraine”, this sort of migraine is generally experienced in three parts. One or two days before the migraine, you may notice subtle changes, such as constipation, mood changes, food cravings, neck stiffness, and increased thirst. This is called the pre-drome. The migraine then presents as throbbing, pulsing pain, usually on one side of the head, but sometimes on both sides. This is called the attack. It often causes nausea, vomiting, and sensitivity to stimuli, especially lights and sounds, but sometimes smells, tastes, and being touched. Usually, migraines last from four to 72 hours. After a migraine, you may feel drained, confused, washed out, (or, more rarely, euphoric) for around a day. This is called the post-drome.
Migraines with auras, also called “classic migraines”, are the same as common migraines, except they also have an additional sensory disturbance called an “aura.” An aura is usually experienced as a temporary visual symptom that tends to start in the center of the field of vision and spread outward. They can present as scotomas (or “blind spots”), zigzag lines, shimmering spots or stars, flashes of light, a general change of vision (blurriness/heightened or dulled color), or vision loss. They can also present as numbness or tingling (usually in one hand or one side of your face), speech or language difficulty, and muscle weakness. Auras usually occur within an hour of the “attack” phase of a migraine and generally last less than 60 minutes. Occasionally, migraine auras occur with only a slight headache or no headache at all, especially in people over the age of 50.
Tension headaches are generally experienced as a mild to moderate pressure, as if a tight rubber band has been wrapped around your head. They can also cause tenderness of the scalp, neck, and shoulder muscles. There are two types of tension headaches: episodic tension headaches and chronic tension headaches. Episodic tension headaches occur less than 15 days a month for at least 3 months. They can last from 30 minutes to an entire week. Chronic tension headaches occur 15 or more days a month for at least 3 months. Generally, they last for at least 3 hours. Tension headaches are the most common sort of headache, but it isn’t clear exactly what causes them.
It’s important to remember that tension headaches are different from migraines (though it is possible to experience both tension headaches and migraines.) The main distinction is that tension headaches usually do not cause visual disturbances, nausea, or vomiting. Also, while migraines are usually aggravated by physical activity, tension headaches are not.
Cluster headaches are an extremely painful type of headache which strikes quickly, usually without warning. The most common symptoms of cluster headaches are excruciating pain (generally behind or around one eye, though it may radiate outward) and restlessness. On the affected side of the head, a cluster headache sufferer may experience excessive tearing, swelling, red-eye, drooping eyelid, stuffy or runny nose, and/or facial sweating. Each individual headache generally lasts from 15 minutes to 3 hours, after which the pain ends as suddenly as it began.
Cluster headaches are so-named because they occur in cyclical bouts of frequent attacks, or “cluster periods.” Cluster periods can last several weeks to several months, during which time headaches usually occur every day, sometimes multiple times a day. Generally, attacks happen at the same time each day, most often at night, usually around one or two hours after falling asleep. Most people with cluster headaches have “episodic cluster headaches”, meaning the headaches occur for one week to a year, followed by a pain-free remission period that can last for as long as a year before another cluster period. In some cases, sufferers have “chronic cluster periods”, which might continue for over a year, with pain-free periods of less than a month.
Secondary Headaches: A secondary headache is a headache that occurs as a symptom of an underlying disease or condition that activates the pain-sensitive nerves in the head.
There are several types of secondary headache. They include:
- External compression headaches caused by wearing something too tightly on your head
- Ice cream headaches or “brain freeze”
- Sinus headaches caused by inflammation/congestion in the sinus cavities
- Spinal headaches caused by issues with spinal fluid loss or low spinal fluid pressure
- Thunderclap headaches or sudden, severe headaches caused by multiple disorders
There are many, many conditions that cause secondary headaches, and both the conditions and the headaches they cause vary greatly in severity and seriousness. Relatively minor issues like ear infections, sinus infections, dehydration, hangovers, and the flu can all cause headaches, as can more potentially serious conditions, such as strokes, aneurysms, brain tumors, encephalitis, and meningitis. For a more extensive list of things that can cause secondary headaches, please consult this site.
The Relationship Between Sleep and Migraines
Sleep and migraines are intimately linked in the majority of migraine sufferers. As we mentioned above, migraines can cause sleep disturbances, and sleep disturbances can trigger migraines. It is for this reason that migraine sufferers are 2 to 8 times more likely to experience sleep problems, including insomnia, sleep apnea, and excessive daytime sleepiness.
Nearly half of all migraines are known as “awakening headaches”, meaning that they occur between 4 AM and 9 AM, waking people from their sleep. The majority of migraine sufferers (71%) have experienced this type of migraine. These headaches often disturb or prevent REM sleep, which leads to chronic sleep deprivation and more severe migraines.
In addition, there are two types of chronic headache that are specifically involved with sleep: cluster headaches and hypnic headaches. We mentioned before that cluster headaches tend to reach the attack phase within one to two hours of falling asleep. Hypnic headaches are headaches that occur only during sleep. The reason these two headaches only attack during sleep may be explained by certain changes the brain goes through during sleep, including the silencing of anti-nociceptive networks (or, networks that block the detection of pain by sensory neurons). When those networks are silenced, the brain is more susceptible to headaches.
There are several other ways in which sleep and migraines influence one another, and by which sleep disturbances can affect the severity of migraines. One study showed that sleep deprivation activates several proteins (specifically, P38, PKA, and P2X3) that lower the threshold for the activation of many of the nerves involved in pain transmission during migraines.
The close relationship between sleep and migraines also has to do with the concept of homeostasis, and how important it is to get good, restful sleep. Homeostasis basically means a well-functioning “body clock”, or a body’s intricate system with which it balances sleep and wakefulness. If the timing of your sleep is set off course from the natural, circadian rhythms of your body clock, the system will try and compensate. One theory holds that triggering a migraine may be a part of that compensation mechanism: migraines caused by too little sleep may be the body’s way of getting you to seek a dark place and lie down, while migraines caused by too much sleep that keep you awake may be the body’s way of trying to reset the sleep-wakefulness equilibrium.
Yet another key association between sleep and migraines has to do with medications commonly used to treat migraines. These medications essentially fall into two categories: those that abort or stop migraine symptoms from progressing once they begin, and those that attempt to prevent migraines from beginning in the first place. In both of those categories, prescription and non-prescription (OTC) medications are commonly used.
Drugs in the first category include OTC pain meds like Aspirin, Naproxen (Naprosyn, Anaprox), Ibuprofen (Motrin), and acetaminophen (Tylenol), as well as prescription barbiturates (such as butalbital). Most OTC and prescription pain medications wear off in 4-8 hours. This makes people vulnerable in the early morning, since the effects of the medication wear off while the person is still asleep. Additionally, overuse of OTC and prescription pain medications can actually cause secondary headaches, and can be a trigger for migraines.
Many sorts of drugs are used in the second category (preventative, or prophylactic), and some of them may also have effects on sleep. Specifically, amitriptyline and propranolol have been shown to suppress rapid eye movement and disturb REM sleep.
Hormonal Migraines and Sleep Loss in Women
For many women, migraines are also linked to hormonal changes, which is one reason why women experience migraines at 2 to 3 times the rate as men. Different hormonal changes, including menstruation, pregnancy, menopause, and the use of hormonal contraception, can affect migraines in different ways.
Up to 19% of women experience migraine attacks around their menstrual period. These migraines occur up to 2 days before, and up to 3 days after, the period begins. These migraines are usually more severe and less responsive to treatment than other types of migraines. They are thought to be triggered particularly by estrogen withdrawal, which occurs naturally in menstruating women.
In some women, hormonal birth control actually reduces the amount or severity of migraines.However, other women are more sensitive to the hormonal changes brought about by this sort of birth control and can experience more frequent or more severe migraines. Some women experience their first migraines when they start taking hormonal birth control.
As is the case with hormonal birth control, some women experience a lessening or even a total disappearance of migraine symptoms during pregnancy. Up to 80% of pregnant people with a history of migraines find that their migraines improve at some point during their pregnancy. In these women, regular nursing may delay the return of migraines after birth. However, for some women (around 15% of pregnant migraine sufferers), migraine symptoms actually worsen during pregnancy.
Migraines may become more frequent and/or more severe during menopause, specifically during perimenopause, which is the period of time leading up to the last menstruation. However, once menopause actually occurs, hormonal migraines drop off significantly in most sufferers. In some women, Hormone Replacement Therapy (HRT) increases migraine symptoms, while in others, it reduces them.
Every increase in the frequency or severity of migraines affects sleep. In each of these instances, specific treatment plans should be considered with your doctor in order to lessen the impact.
How to Get to Sleep When You Suffer From Migraine
Clearly, sleep has an impact on migraines, and vice versa. However, there are many things that people with migraines can do to improve their quality of sleep. Here are the things that are most commonly advised to migraine sufferers to help them get better, healthier, and more restful sleep.
One of the most important parts of managing your migraines is being aware of your body and what tends to set them off. Not every migraine sufferer has a specific set of triggers, but many do. Try keeping a headache diary: every time you get a migraine, write it down and write down everything you were doing, eating, and experiencing before the onset of the attack. You can also use one of several migraine tracking apps. This will help you identify any possible triggers, and will be helpful both for you and for your doctor when developing a course of action to address your symptoms.
Many migraine sufferers benefit from mindfulness meditation, which to focus one’s attention on the present moment. This practice can reduce stress, tension, and anxiety which are some of the most common migraine triggers.
There is a good deal of scientific evidence of mindfulness meditation’s effectiveness as part of a migraine treatment regimen. Specifically, brain imaging found that people with migraines tend to have decreased grey matter volume compared to people without migraines. The more the grey matter volume in the brain decreases, the more frequently migraines tend to attack, and the longer they tend to last. The neurotransmitters often associated with migraines, including dopamine, melatonin, serotonin, cortisol, and norepinephrine, are affected by grey matter depletion. MRI studies have shown that meditation can cause those neurotransmitters to respond in ways that counteract the effects of grey matter depletion. With the help of meditation, dopamine (which is responsible for executive functioning in the brain) and melatonin (which is crucial for the sleep-wake cycle) tend to increase, serotonin (which is perhaps the key neurotransmitter involved in migraines) becomes more regulated, and cortisol and norepinephrine (the “fight or flight” chemicals) decrease.
In addition, people who practice mindfulness tend to report a greater level of control over their bodily responses, including the ability to lessen the impact of migraines. This level of control has the additional benefit of helping some people fall asleep and stay asleep.
Acupuncture has a long history in traditional Chinese medicine, but is sometimes viewed dubiously by Western medical authorities. However, recent studies have shown that acupuncture does have a significant effect on migraines in some people. A review of 22 clinical trials involving 4,985 migraine sufferers showed that acupuncture reduced the frequency of migraine attacks by 50% or more in up to 59% of individuals, which is a similar rate to the use of preventative medications. It’s not entirely clear how acupuncture helps migraines, but it is theorized that the specific pressure points hit by the needles activate pathways in the brain that act as pain blockers.
Exercise can be helpful in the prevention of migraines and in the promotion of sleep. Some people experience migraines when they exercise, and therefore are hesitant to take on exercise as a regular habit. However, avoiding exercise is not healthy, for either overall migraine prevention or for better sleep. Instead, people with migraines should be careful about the ways in which they exercise, to prevent the exertion from causing a migraine. Tips include:
- Staying hydrated before, during, and after exercise.
- Eating sufficient amounts of food around an hour and a half before you exercise.
- Make sure to warm-up, rather than jumping into sudden, vigorous exercise.
When it comes to both migraines and sleep, diet is very important. There are certain foods to avoid in general if you experience migraines, but especially right before bed, including alcohol, caffeine, and coffee. It is advisable not to eat for around two hours before bed, in order to give yourself time to digest.
In addition to avoiding food and drinks that you know to be migraine triggers for you specifically, there are several diets that are recommended specifically for people with migraines. One of the most common diets is a “low tyramine diet.” Tyramine is an amine that is produced in foods from the natural breakdown of the amino acid tyrosine. It is increased in foods when they are aged, fermented, or stored for long periods of time. This diet restricts foods like aged meat, cheese, fermented soy products, MSG, and certain alcohols. Because tyramine is a very common migraine trigger, this diet can reduce migraine frequency, and therefore improve the quality of sleep. Consult with your doctor or a dietician before adopting any specific diet.
Sleep hygiene seems like a strange phrase, but it actually makes a lot of sense. Sleep hygiene refers to the habits you have around bedtime and the environment in which you sleep. Just like regular hygiene, sleep hygiene requires dedication to healthy habits and the construction and maintenance of a healthy environment.
Make sure your sleeping environment is comfortable, quiet, and dark, with well-regulated temperature and airflow. If possible, invest in a high-quality mattress. If you live in a place that’s noisy or where you get too much light through the window at night, consider insulation against noise and blackout curtains.
When it comes to your habits, it’s important to stick to the same sleep routine every night. Try to consistently go to bed at the same time, and have a series of activities in place (for instance, washing your face, brushing your teeth, perhaps reading for half an hour in the living room). As tempting as it may be, try not to read, watch TV, or especially look at your phone while you’re in bed. This will teach your body to more readily associate the bed/sleeping area with sleep.
Otherwise known as CBT, this form of therapy is increasingly practiced by people with migraines and people with sleep disorders. CBT is based on thoughts, feelings, and habits, specifically in reducing harmful thought patterns and activities. It helps you develop skills that increase your ability to handle pain and decrease pain-related stress (which, in turn, helps with the potential vicious cycle of migraines and sleep deprivation triggering one another.) CBT as a treatment for migraines is backed by scientific evidence: studies have found that group and one-on-one cognitive behavioral therapy in people with migraines and tension-type headaches resulted in a significant reduction in average intensity and frequency of migraines, as well as unhelpful, potentially stressful thoughts about migraines, sleep, and coping habits.
Biofeedback is a technique used for a number of conditions, disorders, and diseases, including migraines and insomnia. During a biofeedback session, you are connected to electrical sensors that help you receive information about your body, including brain waves, breathing, heart rate, muscle contractions, sweat gland activity, and temperature. This feedback is interpreted to you in a way that helps you become more aware of the processes in your body, and that therefore allows you to make subtle changes to your body (such as relaxing certain muscles and changing your breathing.) Some studies have shown that biofeedback is helpful for migraine patients.
When suffering from chronic migraines, your doctor can be a crucial advocate and source of information. Most people with migraines have a varied treatment plan that includes several different lifestyle changes, and sometimes medical changes and treatments. A good doctor will have the most up-to-date information on migraines and on what treatment plan is right for you.
It is also important to remember that certain headaches and migraines need urgent medical attention. The vast majority of headaches do not need emergency care, but it is crucial to be aware of the ones that do. Contact a doctor or your closest emergency care center if:
- Your headache is unusually severe or steadily worsens uncharacteristically
- Your headache follows a blow to the head or any other head injury.
- Your hear headache is accompanied by a stiff neck, confusion, fever, slurred speech, seizures, or uncharacteristic weakness, visual disturbances, or numbness.
Learn More About Migraines and Sleep
Migraines can be absolutely devastating and overwhelming, and it’s easy to feel like it’s all too much. However, you are not alone. There are many resources for people with migraines, and a vast network of people who know what you’re going through and want to help.
- Migraine Research Foundation: An organization focused on migraine research, as well as advocacy and support for people with migraines.
- American Migraine Foundation: Founded by the American Headache Society, this group focuses specifically on research and education that will lead to an improvement in the lives and treatment of people with migraines.
- Speak Your Migraine: This combination migraine advocacy site and resource center allows you to find migraine-specific doctors and migraine tracking tools, as well as sharing your personal story about how migraines affect your life.
- Danielle Byron Henry Migraine Foundation: Come here for support and access to treatment for migraine patients, with a specific focus on children and young adults.
- Best Headache and Migraine Blogs of 2019: Healthline.com’s annual compilation of the best blogs by, for, and about people with headaches and migraines, including The Migraine Diva, My Migraine Life, and The Migraine Mantras.
- MigraineAgain.com: This is a private network of people who experience migraines and those who love them. It is a safe, understanding social space where you can talk through the migraine struggle.
- Migraine.org: A comprehensive network with a well-researched body of articles and a vetted list of migraine-educated medical professionals.
- Yoga for Migraine Headaches: A very well curated series of instructional videos with stretches that may relieve various migraine symptoms.
- More to Migraine: A reliable source of tips for living your best life while managing migraines.
- List of Comprehensive Headache Centers: The Migraine Research Foundation’s list of vetted, multidisciplinary centers that treat chronic headache and migraine conditions.