Tension-type headache and sleep apnea in the general population

Sleep Bruxism and Obstructive Sleep Apnea Are Not Risk Factors for Tension-Type Headache (TTH): A Polysomnographic Study

Background: Tension-type headache (TTH) is the most common primary headache. Obstructive sleep apnea (OSA) and sleep bruxism (SB) are two of the most common sleep disorders; however, the relationship between TTH, OSA, and SB has not been conclusively proved in the literature. The objective of our study was to estimate potential associations with OSA and SB in TTH subjects. Methods: 108 adult individuals who underwent polysomnography (vPSG) were included, and the group was divided into two subgroups: TTH (n = 34) and control (n = 74). The International Classification of Headache Disorders (ICHD-3) guidelines were used to diagnose TTH. OSA and SB diagnoses were based on vPSG examination with electromyographic (EMG) recordings and the American Academy of Sleep Medicine (AASM) criteria. The results were analyzed, where p < 0.05 was considered to be statistically significant. Results: In the TTH group, the incidence of SB was more than two times lower than the control (OR = 0.41, 95% CI: 0.17-0.96, p < 0.05). However, the incidence of severe SB (BEI > 4) was similar in the TTH and control groups (OR = 0.54, 95% CI: 0.21-1.35, p > 0.05). Additionally, phasic and tonic SB episodes were less frequent in the TTH group compared to the controls (p < 0.05). The mean apnea-hypopnea index (AHI) was not significantly different between the TTH and control groups (p > 0.05). The sleep architecture and respiratory disturbances did not differ between the examined groups (p > 0.05). Conclusions: SB is not a risk factor for TTH. Moreover, severe SB is not connected with TTH. OSA is not a risk factor for TTH. Sleep quality did not differ between both groups during PSG; therefore, TTH may not change sleep structure. The mechanism of these findings is still unclear, and further studies should explain in detail the association between TTH and OSA.

Prevalence of functional disorders across Europe: a systematic review and meta-analysis

Functional Disorders (FD) refer to persistent somatic symptoms caused by changes in the functioning of bodily processes. Previous findings suggest that FD are highly prevalent, but overall prevalence rates for FD in European countries are scarce. Therefore, the aim of the present work was to estimate the point prevalence of FD in adult general populations. PubMed and Web of Science were searched from inception to June 2022. A generalized linear mixed-effects model for statistical aggregation was used for statistical analyses. A standardized quality assessment was performed, and PRISMA guidelines were followed. A total of 136 studies were included and systematically synthesized resulting in 8 FD diagnoses. The large majority of studies was conducted in the Northern Europe, Spain, and Italy. The overall point prevalence for FD was 8.78% (95% CI from 7.61 to 10.10%) across Europe, with the highest overall point prevalence in Norway (17.68%, 95% CI from 9.56 to 30.38%) and the lowest in Denmark (3.68%, 95% CI from 2.08 to 6.43%). Overall point prevalence rates for specific FD diagnoses resulted in 20.27% (95% CI from 16.51 to 24.63%) for chronic pain, 9.08% (95% CI from 7.31 to 11.22%) for irritable bowel syndrome, and 8.45% (95% CI from 5.40 to 12.97%) for chronic widespread pain. FD are highly prevalent across Europe, which is in line with data worldwide. Rates implicate the need to set priorities to ensure adequate diagnosis and care paths to FD patients by care givers and policy makers.

Prevalence of headaches and their relationship with obstructive sleep apnea (OSA) - Systematic review and meta-analysis

Obstructive sleep apnea (OSA) is one of the most common sleep disorders; however, there are inconsistent results about the connection and occurrence of primary and secondary headaches in OSA. Therefore, the primary objectives were to estimate the prevalence and potential relationship between all types of headaches and OSA. A systematic review was conducted according to PRISMA 2020 guidelines. Studies were searched in PubMed, Embase, and Web of science up to July 2023. The Joanna Briggs Institute tool assessed the risk of bias. 1845 articles were identified, and 23 studies describing 15,402 patients were included. Pooled prevalence of all headaches in OSA was 33% (95% CI: 0.25-0.41), 33% for morning headaches (95% CI: 0.24-0.45), 25% for sleep apnea headaches (95% CI: 0.18-0.34), 19% for tension-type headache (95% CI: 0.15-0.23), and 16% for migraine (95% CI: 0.09-0.26). Relative risk for the occurrence of headache in OSA patients compared to the non-OSA people was 1.43 (95% CI: 0.92-2.25). OSA females and males had morning headaches with similar frequency. The prevalence of headaches in OSA was moderate. OSA did not increase the risk of headache. There is a need to conduct further studies focused on bidirectional connections between sleep disorders and headaches.

Secondary Headache: Current Update

PURPOSE

The purpose of this paper is to review some of the causes of secondary headache particularly focusing on the subcategories of secondary headache in the International Classification of Headache Disorders, 3rd edition, the clinical features of these headaches, and their associated features and management.

OVERVIEW

Headache attributed to trauma or injury to the head and/or neck, headache attributed to cranial or cervical vascular disorder, headache attributed to non-vascular intracranial disorder, headache attributed to a substance or its withdrawal, headache attributed to infection, headache attributed to disorder of homeostasis, and headache or facial pain attributed to disorder of the cranium, neck, eye, ears, nose, sinuses, teeth, mouth, or other facial or cervical structure are discussed in this paper.

DISCUSSION

Headache is a common symptom of multiple medical conditions. Although a minority of headache patients have a secondary basis for their headaches, it is important to identify clinical features of secondary headache disorders including both the headache and non-headache features of the condition, diagnose the secondary etiology correctly, and treat them appropriately.

Study of Sleep Disorders and Polysomnographic Evaluation among Primary Chronic Daily Headache Patients

Objective:

Studies related to sleep disorders and polysomnography (PSG) among chronic daily headache patients are rare. We studied this and compared chronic migraine (CM) with chronic tension-type headache.

Methods:

Eighty-three patients were recruited. They were evaluated by semi-structured interview, headache, and sleep diaries along with Epworth Sleepiness Scale score and insomnia symptom score. Overnight PSG was performed and data compared.

Results:

Chronic tension-type headache was more common than CM, both having female preponderance. Insomnia followed by excessive daytime sleepiness was prevalent sleep disorder. Sleep efficiency and Stage 3 sleep were lower in CM compared to chronic tension-type. ESSS was significantly increased among chronic tension-type patients. No significant correlation was found among PSG parameters in patients with or without sleep disorders.

Conclusion:

Insomnia being most common sleep disorder among chronic headache population. Chronic tension-type headache had slightly better slow-wave sleep than CM and significantly increased daytime sleepiness.

Increased risk of sleep apnoea among primary headache disorders: a nationwide population-based longitudinal study

Background

Primary headache disorders (PHDs) are associated with sleep problems. It is suggested that headache and sleep disorder share anatomical and physiological characteristics. We hypothesised that patients with PHDs were exposed to a great risk for developing sleep apnoea (SA).

Methods

In this retrospective longitudinal study, the data obtained from the Longitudinal Health Insurance Database in Taiwan were analysed. The study included 1346 patients with PHDs who were initially diagnosed and 5348 patients who were randomly selected and age/sex matched with the study group as controls. PHDs, SA, comorbidities and other confounding factors were defined based on International Classification of Diseases, Ninth Revision, Clinical Modification. Cox proportional hazards regressions were employed to examine adjusted HRs after adjusting with confounding factors.

Results

Our data revealed that patients with PHDs had a higher risk (HR 2.17, 95% CI 1.259 to 3.739, p<0.05) to develop SA compared with matched cohorts, whereas patients with migraine exhibited a high risk (HR 2.553, 95% CI 1.460 to 4.395, p<0.01). The results showed that patients with PHDs aged 18–44 exhibited highest risk of developing SA. In addition, males with PHDs exhibited an HR 3.159 (95% CI 1.479 to 6.749, p<0.01) for developing SA, respectively. The impact of PHDs on SA risk was progressively increased by various follow-up time intervals.

Conclusion

Our results suggest that PHDs are linked to an increased risk for SA with sex-dependent and time-dependent characteristics.

Sleep and Orofacial Pain

Sleep and pain share a bidirectional relationship. Therefore, it is important for practitioners managing patients experiencing either sleep and/or pain issues to recognize and understand this complex association from a neurobiological perspective involving neuroanatomic and neurochemical processes. Accounting for the influence of pain on the various aspects of sleep and understanding its impact on various orofacial pain disorders assists in developing a prudent management approach. Screening for sleep disorders benefits practitioners in identifying these individuals. Instituting evidence-based multidisciplinary management strategies using both behavioral and pharmacologic strategies enhances the delivery of appropriate care.

Sleep apnoea and the neurologist

There is increasing awareness and interest in the complex and extensive inter-relationships between sleep disorders and neurological disorders. This review focuses on the clinical interactions between obstructive sleep apnoea and stroke, headaches, epilepsy, cognition and idiopathic Parkinson's disease. We highlight to the neurologist the importance of taking a sleep history and considering the diagnosis and treatment of obstructive sleep apnoea.

Sleep and chronic daily headache

Sleep and headache have a complex and extensive interrelationship. This review focuses on the relationship between sleep and chronic daily headache, examining recent advances in the epidemiology and insights into possible mechanisms of this relationship as well as reviewing advances in treatment. There is a clear relationship between obstructive sleep apnoea (OSA) and snoring and morning headache, but the relationship between OSA and snoring and other primary headaches requires clarification. OSA and chronic migraine share both obesity and patent foramen ovale (PFO) as possible co-morbidities. Hypoxia does not clearly predispose to morning headache. Continuous positive airway pressure (CPAP) is an established treatment for OSA, and mixed results have been reported with regards to headache improvement with this treatment.

Headaches and sleep disorders

Headaches and sleep disorders are associated in a complex manner. Both the disorders are common in the general population, but the relationship between the two is more than coincidental. Sleep disorders can exacerbate headache sand the converse is also true. Treatment of sleep disorders can have a positive impact on the treatment of headaches. Screening for sleep disorders should be considered in all patients with headaches. This can be accomplished with brief screening tools. Those who screen positively can be further evaluated or referred to asleep specialist.

Tension-type headache associated with obstructive sleep apnea: a nationwide population-based study

BACKGROUND

There is still controversy regarding the association between primary headaches and obstructive sleep apnea. We explored the relationship between tension-type headache (TTH) and obstructive sleep apnea (OSA) using a large nationwide population-based data set in Taiwan.

METHODS

We identified 4759 patients diagnosed with OSA from the Taiwan Longitudinal Health Insurance Database, based on polysomnography, as the OSA group. We then randomly selected 19036 subjects without OSA, matched by sex and age, to serve as the non-OSA group. The multivariate Cox proportional hazards model with matching for age and sex was used to assess the possible associations between TTH and OSA among the patients.

RESULTS

The prevalence of TTH was 10.2% among OSA patients and 7.7% among non-OSA patients (p < 0.001). The multivariate Cox proportional hazards model revealed patients with OSA were more likely to have TTH (hazard ratio, 1.18; 95% CI, 1.06-1.31) (p = 0.003) than patients in the non-OSA group.

CONCLUSION

Patients with OSA had a higher likelihood of developing TTH than patients in the non-OSA group. Further studies of physiological patterns between OSA and TTH are needed to confirm the study findings.

Headache in sleep apnea syndrome: Epidemiology and pathophysiology

This review investigates the relation between obstructive sleep apnea and sleep apnea headache, migraine and tension-type headache. Focus is made on studies from the general population with interviews conducted by a physician and obstructive sleep apnea confirmed by polysomnography.

Obstructive sleep apnea syndrome is observed in 3% of the middle-aged population. The prevalence of sleep apnea headache in this population is 12%–18%, while morning headache with similar symptomatology as sleep apnea headache occur in 5%–8% of the general population. People with sleep apnea headache did have significantly more minutes below 90% oxygen saturation (23.1 min vs. 1.9 min, p = 0.002), higher level of average oxygen desaturation (5.9% vs. 4.5%, p < 0.001) and lower average of the lowest oxygen saturation (80.9% vs. 88.5%, p < 0.001) than people with morning headache. A comparison of those with obstructive sleep apnea with or without sleep apnea headache showed no significant differences. Thus, oxygen desaturation alone cannot explain the pathophysiology of sleep apnea headache.

Obstructive sleep apnea and migraine, and obstructive sleep apnea and tension-type headache are not related in the general population.

The cause of sleep apnea headache remains to be elucidated.

Prevalence and predictors of headache in patients referred to polysomnography

Background

The objectives of this study were; (1) to assess the prevalence and frequency of headache in patients referred to polysomnography (PSG) due to a clinical suspicion of obstructive sleep apnea (OSA) or another sleep disturbance and compare with a reference population, and (2) to assess the association of OSA severity with headache and headache frequency.

Methods

A total of 784 participants filled in a headache questionnaire between 2003 and 2009 at the Department of Clinical Neurophysiology, Akershus University Hospital. Of these patients 477 were suspected to have OSA, and 307 had other sleep complaints. We assessed the prevalence of headache and monthly headache frequencies, as well as sleep apnea severity using an apnea-hypopnea index (AHI). The association of headache and monthly headache frequencies with PSG subgroups was assessed using multivariate logistic and ordered logistic regression analysis.

Results

The frequency of headache was not associated with the severity of OSA. Patients referred to a sleep study for any reason had higher odds ratio (OR) for having experienced headache during the past year than population controls after adjustment for age, gender and education, i.e. patients with normal AHI had OR of 3.56, patients with OSA had OR of 3.51, and patients with other sleep disturbances had OR of 3.33. Similarly, the adjusted OR of being in a higher category of monthly headache frequency compared to controls was higher in those with normal AHI (OR 3.42), OSA (OR 3.29), and other sleep disturbances (OR 3.00).

Conclusions

The odds of headache and headache frequency were higher in subjects referred to a PSG for any sleep disturbance independently of OSA, compared to general population controls. However, there was no association between experiencing headache during the past year or headache frequency with OSA severity.

Sleep apnea headache: a growing concern in an increasingly obese population?

Sleep apnea headache is a recurrent universal pressing headache without accompanying symptoms at awakening that resolves within 4 h. The diagnosis requires polysomnography-verified apnea hypopnea index≥5, that is, obstructive sleep apnea (OSA). Morning headache has similar symptomatology without OSA. The prevalence of sleep apnea headache is 10-15% in people with OSA, whereas morning headache occurs in 5%. The severity of OSA only slightly affects the prevalence of sleep apnea headache. The pathophysiology of sleep apnea headache remains an enigma, since average oxygen desaturation and lowest oxygen saturation are similar in OSA people without sleep apnea headache. Migraine and tension-type headache are unrelated to OSA. Thus, growing concern of sleep apnea headache in an increasingly obese population is unfounded with our current knowledge.

Sleep loss as risk factor for neurologic disorders: a review

Sleep loss refers to sleep of shorter duration than the average baseline need of seven to eight hours per night. Sleep loss and sleep deprivation have severe effects on human health. In this article, we review the main aspects of sleep loss, taking into account its effects on the central nervous system. The neurocognitive and behavioral effects of sleep loss are well known. However, there is an increasing amount of research pointing to sleep deprivation as a risk factor for neurologic diseases, namely stroke, multiple sclerosis, Alzheimer's disease, headache, epilepsy, pain, and somnambulism. Conversely, sleep loss has been reported to be a potential protective factor against Parkinson's disease. The pathophysiology involved in this relationship is multiple, comprising immune, neuroendocrine, autonomic, and vascular mechanisms. It is extremely important to identify the individuals at risk, since recognition and adequate treatment of their sleep problems may reduce the risk of certain neurologic disorders.

Improvement in headaches with continuous positive airway pressure for obstructive sleep apnea: a retrospective analysis

OBJECTIVE

We aimed to identify clinical features in patients with severe headaches that predicted obstructive sleep apnea (OSA) and determine clinical and sleep study characteristics that predicted headache improvement with continuous positive airway pressure (CPAP).

BACKGROUND

Many patients with headaches complain of sleep symptoms and have OSA. There is often improvement of headaches with CPAP treatment.

METHODS

We conducted a retrospective chart review of all patients referred to adult neurology clinic for headaches and sent for polysomnography between January 2008 and December 2009. Follow-up ranged from 18 to 42 months.

RESULTS

Eighty-two headache patients (70 females, 12 males) were studied. Mean age was 45±13 years (females 45±13, males 43±11) and mean body mass index was 32±9. Headache types included 17% chronic migraine without aura, 22% episodic migraine without aura, 32% migraine with aura, 21% tension-type headache, 6% chronic post-traumatic headache, 11% medication overuse headache, and 7% other types. All patients were receiving standard treatment for their headaches by their neurologist. Fifty-two patients (63%) had OSA. Increasing age, female gender, and chronic migraine without aura were predictive of OSA. Of the patients with OSA, 33 (63%) used CPAP and 27 (82%) were adherent to CPAP. Headache improvement was reported by 40 patients (49%) due to either standard medical therapy or CPAP. Patients with OSA who were CPAP adherent (21/27) were more likely to have improvement in headaches than patients intolerant of CPAP (2/6), those that did not try CPAP (8/19), and those who did not have OSA (16/30) (P=.045). Of the 33 patients who used CPAP, 13 reported improvement in headaches specifically due to CPAP therapy and 10 additional patients noted benefit in sleep symptoms. The presence of witnessed apneas (P=.045) and male gender (P=.021) predicted improvement in headaches due to CPAP.

CONCLUSIONS

Headache patients should be evaluated for the presence of OSA. Treating OSA improves headaches in some patients.

Chronic headaches and insomnia: working toward a biobehavioral model

BACKGROUND

Sleep disturbances are consistently associated with chronic headaches, yet the mechanisms underlying this relationship remain unclear. One potential barrier to generating new hypotheses is the lack of synthesis between models of headache and models of sleep. The goal of this paper is to present a perspective on the chronification of migraine and tension-type headaches based upon conceptual models used in sleep research.

METHODS

We provide a critical review of the literature on sleep and headache, highlighting the limitations in sleep methodology. Models of sleep physiology and insomnia are discussed, along with the potential implications for the chronification of migraine and tension-type headache. In addition, we propose a biobehavioral model that describes the interaction between behaviors related to coping with headache, the impact of these behaviors on insomnia and sleep physiology and the downstream propensity for future headache attacks.

CONCLUSIONS

We hope that this perspective will stimulate interdisciplinary activity toward uncovering the pathway for more effective interventions for chronic headache patients.

Tension-type headache and systemic medical disorders

Tension-type headache (TTH) is the most common form of headache in the general population. Diagnosis of TTH is based merely on clinical features and on careful exclusion of all possible causes of headache. Most of the headaches that present in the context of medical disorders (e.g., hypothyroidism, sleep disorders, and hypertensive crisis) have clinical features overlapping with those of TTH; medical history and specific features of the systemic disorder are usually the clues to establish a correct diagnosis. Some medical disorders may worsen a preexisting TTH, and is also possible the comorbidity of TTH with psychiatric disorders and fibromyalgia.