Migraine and sleep deprivation: integrative review

Thomaz, Tania Gouvêa; Paula, Ana Ester Amorim de; Alves, Daniel de Moraes; Alves, Luana Lemos; Fonseca, Pedro Guilherme Mol da

doi:10.5935/2595-0118.20210068

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REVIEW ARTICLE • BrJP 4 (4) • Oct-Dec 2021 • https://doi.org/10.5935/2595-0118.20210068 copy

Migraine and sleep deprivation: integrative review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

BACKGROUND AND OBJECTIVES:

Migraine is a type of primary headache, and its pathophysiology remains incomplete. The relationship between sleep and migraine is easily identified by migraine patients. The aim of this review was to investigate the relationship between sleep deprivation and migraine.

A search was made for articles using the terms: “migraine” and “sleep deprivation” in the Pubmed, Biblioteca Virtual da Saúde (Virtual Health Library - LILACS and IBECS) and Scielo databases. The first analysis was based on title and abstract. In cases where the title and abstract were not clear, the article was accessed in its entirety. After applying the exclusion criteria, 49 articles remained. These articles were analyzed and organized into two tables: one for articles that treated sleep as a trigger and the other for articles that explored the pathophysiological relationship between sleep and migraine.

CONCLUSION:

It is possible that sleep deprivation causes or worsens migraine crisis due to its ability to cause oxidative stress in the brain. This in turn activates TRPA1 receptors located on first-order trigeminal neurons. Activation of these receptors initiates the sensitization process of the trigeminal system that culminates with the antidromic release of calcitonin gene-related peptide in the dural afferents of these neurons in the trigeminal ganglion. The relationship between insomnia and migraine seems to converge with this same pathophysiological process, since sleep deprivation imposed by insomnia would be able to generate a migraine crisis through increased oxidative stress.

Keywords:
Headache; Migraine disorders; Sleep deprivation

Authors	Sleep as trigger
Rasmussen¹⁷17 Rasmussen BK. Migraine and tension-type headache in a general population: precipitating factors, female hormones, sleep pattern and relation to lifestyle. Pain. 1993;53(1):65-72.	Sleep deprivation or decreased sleep functions as a trigger for both migraine and TTH patients.
Robbins¹⁸18 Robbins L. precipitating factors in migraine: a retrospective review of 494 patients. Headache. 1994;34(4):214-6.	Poor sleep or not enough sleep are considered triggers for migraine patients, whereas few patients identify oversleeping as a trigger for their attacks.
Turner et al.¹⁹19 Turner LC, Molgaard CA, Gardner CH, Rothrock J F, Stang PE. Migraine trigger factors in a non-clinical Mexican-American population in San Diego county: implications for etiology. Cephalalgia. 1995;15(6):523-30.	Fatigue and sleep are more relevant triggers for men than women.
Alders, Hentzen and Tan²⁰20 Alders EE, Hentzen A, Tan CT. A community-based prevalence: study on headache in Malaysia. Headache. 1996;36(6):379-84.	Sleep deprivation is a frequent trigger for both migraine and TTH.
Chabriat et al.²¹21 Chabriat H, Danchot J, Michel P, Joire JE, Henry P. Precipitating factors of headache a prospective study in a national control-matched survey in migraineurs and nonmigraineurs. Headache. 1999;39(5):335-8.	Fatigue and sleep alterations are the most frequent triggers in both migraine and non-migraine populations.
Bánk and Márton²²22 Bánk J, Márton S. Hungarian Migraine Epidemiology. Headache. 2000;40(2):164-9.	Sleep deprivation is one of the most common triggers of migraine with and without aura.
Spierings, Ranke and Honkoop²³23 Spierings ELH, Ranke AH, Honkoop PC. Precipitating and aggravating factors of migraine versus tension-type headache. Headache. 2001;41(6):554-8.	Sleep deprivation is one of the main triggers for migraineurs and especially for TTH patients.
Ierusalimschy and Moreira Filho²⁴24 Ierusalimschy R, Moreira Filho P F. Fatores desencadeantes de crises de migrânea em pacientes com migrânea sem aura. Arq Neuropsiquiatr. 2002;60(3-A):609-13.	Sleep deprivation is one of the main triggers in migraine patients, whereas oversleeping is infrequently reported.
Zivadinov et al.²⁵25 Zivadinov R, Willheim K, Sepic-Grahovac D, Jurjevic A, Bucuk M, Brnabic-Razmilic O, et al. Migraine and tension-type headache in Croatia: a population-based survey of precipitating factors. Cephalalgia. 2003;23(5):336-43.	Sleep disturbances are frequent triggers in TTH patients and with more relevance in migraine patients.
Karli et al.²⁶26 Karli N, Zarifoglu M, Calisir N, Akgoz S. Comparison of pre-headache phases and trigger factors of migraine and episodic tension-type headache: do they share similar clinical pathophysiology? Cephalalgia. 2005;25(6):444-51.	Sleep alterations are the most frequent triggers for migraineurs, individuals with typical aura without headache, and TTH patients.
Wöber et al.²⁷27 Wöber C, Holzhammer J, Zeitlhofer J, Wessely P, Bingol Ç W. Trigger factors of migraine and tension-type headache: experience and knowledge of the patients. J Headache Pain. 2006;7(4):188-95.	Sleep deprivation and change in nightly habits are not identified as relevant triggers in the general population when compared to patients in specialized outpatient clinics.
Kelman²⁸28 Kelman L. The triggers or precipitants of the acute migraine attack. Cephalalgia. 2007;27(5):394-402.	Poor quality sleep is a trigger for migraineurs. Some patients identify sleeping late as a trigger.
Fukui et al.²⁹29 Fukui PT, Gonçalves TR, Strabelli CG, Lucchino NM, Matos FC, et al. Trigger factors in migraine patients. Arq Neuropsiquiatr. 2008;66(3-A):494-9.	Sleep alterations are frequent triggers in migraineurs.
Bokhari et al.³⁰30 Bokhari FA, Sami W, Shakoori TA, Ali SA, Qureshi GA. Clinical characteristics of 226 college-going female migraineurs in Lahore, Pakistan - putting ICHD-2 to the road test. Neuro Endocrinol Lett. 2008;29(6):965-70.	Sleep deprivation is the most common trigger in migraineurs. Sleep is a frequent relief factor for them.
Andress-Rothrock, King and Rothrock³¹31 Andress-Rothrock D, King W, Rothrock J. An analysis of migraine triggers in a clinic-based population. Headache. 2010;50(8):1366-70.	Poor sleep or not enough sleep are considered triggers for migraine patients.
Yadav, Kalita and Misra³²32 Yadav RK, Kalita J, Misra UK. A Study of triggers of migraine in India. Pain Med. 2010;11(1):44-7.	Sleep deprivation is a common trigger in Indian migraineurs when compared to other populations.
Carod-Artal et al.³³33 Carod-Artal FJ, Ezpeleta D, Martín-Barriga ML, Guerrero AL. Triggers, symptoms, and treatment in two populations of migraneurs in Brazil and Spain A cross-cultural study. J Neurol Sci. 2011;304(1-2):25-8.	Sleep deprivation is one of the most frequent triggers in Brazilian and Spanish migraineurs, with higher prevalence in the Brazilian population.
Haque et al.³⁴34 Haque B, Rahman KM, Hoque A, Hasan AT, Chowdhury RN, Khan SU, et al. Precipitating and relieving factors of migraine versus tension type headache. BMC Neurol. 2012;12:82.	Sleep deprivation is more common as a trigger in migraine than in TTH. However, sleep is a similar relief factor for both migraine and TTH.
Wang et al.³⁵35 Wang J, Huanga Q, Li N, Tana G, Chenb L, Zhou J. Triggers of migraine and tension-type headache in China: a clinic-based survey. Eur J Neurol. 2013;20(4):689-96.	Sleep alterations are the main trigger among migraineurs, while among TTH patients it’s the second trigger.
Iliopoulos et al.³⁶36 Iliopoulos P, Damigos D, Kerezoudi E, Limpitaki G, Xifaras M, Skiada D, et al. Trigger factors in primary headaches subtypes: a cross-sectional study from a tertiary center in Greece. BMC Res Notes. 2015;8:393.	Sleep deprivation is one of the most common triggers for migraine, with or without aura, and TTH. Oversleeping is a more frequent trigger in individuals suffering from migraine with aura.
Park et al.³⁷37 Park J W, Chu MK, Kim JM, Park SG, Cho SJ. Analysis of trigger factors in episodic migraineurs using a smartphone headache diary applications. PLoS One. 2016;11(2):e0149577.	Sleep deprivation is one of the most frequent triggers in episodic migraine.
Peris et al.³⁸38 Peris F, Donoghue S, Torres F, Mian A, Wober C. Towards improved migraine management: Determining potential trigger factors in individual patients. Cephalalgia. 2017;37(5):452-63.	Non-adequate sleep is one of the main triggers for migraineurs.
Lisicki et al.³⁹39 Lisicki M, Romagnoli ER, Piedrabuena R, Giobellina R, Schoenen J, Magis D. Migraine triggers and habituation of visual evoked potentials. Cephalalgia. 2018;38(5):988-92.	On average, migraineurs have four different triggers, with sleep deprivation being one of them.
Portela et al.⁴⁰40 Portela MC, Becerra DE, Zapata J P, Martínez JD, Rodriguez LM. Prevalencia de migraña y caracterización de una población estudiantil universitaria, Medellín, 2014. Med UPB. 2018;37(2):107-15.	Sleep deprivation is one of the most common triggers in the college students population studied, similarly to the general population.
Tai et al.⁴¹41 Tai MS, Yet SXE, Lim TC, Pow YZ, Goh CB. Geographical differences in trigger factors of tension-type headaches and migraines. Curr Pain Headache Rep. 2019;23(2):12.	Regardless of geographic location, sleep deprivation is one of the main triggers for migraine and TTH.

Authors	Objectives and Methodologies	Results	Conclusions
Blau²2 Blau JN. Migraine pathogenesis: the neural hypothesis reexamined. J Neurol Neurosurg Psychiatry. 1984;47(5):437-42.	Analyze the hypothesis that migraine is a primary neurological disorder with secondary vascular manifestations.	Sleep, besides being a trigger for migraine, may also be a way to resolve crisis. In addition, sleepiness is considered a symptom of migraine.	It’s proposed that specific sensory areas of the cortex and hypothalamus may act as areas where a migraine attack is initiated.
Sahota and Dexter⁶6 Sahota RK, Dexter JD. Sleep and headache syndromes: a clinical review. Headache. 1990;30(2):80-4.	Assess the association between sleep and headaches.	Migraine seems to be associated with an increase in REM sleep and stages III and IV of non-REM sleep. This association is related to sleep quality rather than the circadian rhythm. A period of sleep may resolve the crisis.	Given the close anatomical and neurochemical associations between headache and sleep, it’s feasible to consider the existence of a common substrate for these two phenomena.
Inamorato, Minattihanntjch and Zukerman⁴²42 Inamorato E, Minatti-Hanntjch SN, Zukerman E. The role of sleep in migraine attacks. Arq Neuropsiquiatr. 1993;51(4):429-32.	Clarify the relationship between migraine and sleep.	Patients report that sleep can affect them in one or several ways. When only one way was reported, relief was the most frequent. For those who report multiple ways of interaction, migraine attacks may be triggered by sleep deprivation or sleep excess.	Patients identify that sleep affects them in a single or multiple ways, this suggests that there are multiple pathophysiological mechanisms contributing to the crisis.
Kelman and Rains⁴³43 Kelman L, Rains JC. Headache and sleep: examination of sleep patterns and complaints in a large clinical sample of migraineurs. Headache. 2005;45(7):904-10.	Examine sleep complaints in relation to headache frequency and severity.	Headache is triggered by sleep deprivation or excessive sleep. Sleep can also be a relieving factor. Migraineurs with few hours of sleep (<6h) have more frequent and intense headaches than migraineurs with more hours of sleep and are more likely to have morning episodes.	The group that doesn’t get enough sleep exhibits a more severe and frequent pain pattern. Sleep complaints occur more frequently among patients with chronic headache.
Calhoun and Ford ¹³13 Calhoun AH, Ford S. Behavioral sleep modification may revert transformed migraine to episodic migraine. Headache. 2007;47(8):1178-83.	Evaluate the impact of BSM on chronic migraine in women.	The group undergoing BSM report a reduction in headache frequency and intensity. Those who sleep less are more likely to transform migraine chronic to episodic	Behavioral sleep intervention was associated with improvement in headache frequency and intensity, as well as making attacks sporadic.
Gallup and Gallup⁴⁴44 Gallup AC, Gallup GG JR. Yawning and thermoregulation. Physiol Behav. 2008;95(1):10-6.	Evaluate the physiological substrate of yawning on thermoregulation.	In rats, prolonged sleep deprivation has been shown to increase brain temperature, which causes yawning.	Migraine has been associated with thermoregulatory dysfunction and atypical yawning. This mechanism could explain the relationship between sleep deprivation and the onset of a migraine attack.
Rains⁷7 Rains JC. Optimizing circadian cycles and behavioral insomnia treatment in migraine. Curr Pain Headache Rep. 2008;12(3):213-9.	Discuss the nature and prevalence of sleep complaints in patients with migraine.	In most cases, insomnia preceded migraine. Chronic insomnia is significantly related to headache. Sleep dysregulation can cause or reduce headache thresholds.	Insomnia is the most common sleep disorder in patients with headache. Recent evidence suggests that migraine can be relieved with better sleep regulation, either by drug or behavioral therapy.
Yeung, Chung and Won ⁴⁵45 Yeung WF, Chung KF, Won CY. Relationship between insomnia and headache in community-based middle-aged Hong Kong Chinese women. J Headache Pain. 2010;11(3):187-95.	Assess the frequency of headache, sleep difficulties, mood disturbances, and functional impairment in women through a self-administered questionnaire.	Women with headache are significantly more likely to report symptoms of insomnia than those without headache. The prevalence of these symptoms is uniform among women with unspecified headache, TTH, and migraine.	The association between insomnia and headache is more evident as the number of headache episodes increases. Middle-aged women with symptoms of anxiety, depression, and sleep disturbances are at increased risk for headache.
Lovati et al.¹⁵15 Lovati C, D’Amico D, Raimondi E, Mariani C, Bertora P. Sleep and headache: a bidirectional relationship. Expert Review of Neurotherapeutics. 2010;10(1):105-17.	Review the anatomy and physiology of sleep disorders associated with perceived headache.	Sleep quality is related to the presence of allodynia associated with migraine.	Sleep disorders may favor central sensitization of the trigeminal nucleus causing allodynia, which in turn may undermine sleep.
Lateef et al.¹⁶16 Lateef T, Swanson S, Cui L, Nelson K, Nakamura E, Merikangas K. Headaches and sleep problems among adults in the United States: Findings from the National Comorbidity Survey–Replication Study. Cephalalgia. 2010;31(6):648-53.	Assess whether migraine differs from non-migraine headache in terms of insomnia and the severity of sleep disturbances.	Adults with headache report greater difficulty in: initiating sleep, staying asleep, and waking up early in the morning. In addition, they have more fatigue during the day.	Adults with headache have a greater risk of developing sleep disturbance regardless of the type of headache.
Houle et al.⁴⁶46 Houle TT, Butschek RA, Turner DP, Smitherman TA, Rains JC. Stress and sleep duration predict headache severity in chronic headache sufferers. Pain. 2012;153(12):2432-40.	Evaluate the relationships between stress, sleep duration, and headache in patients with chronic headaches (migraine or TTH).	Two consecutive days of high stress or not enough sleep were strongly predictive of headache, whereas two days of low stress or adequate sleep were protective.	Headache risk increases proportionally with high stress and low sleep: these are strongly correlated and impact one another.
Tran and Spierings⁸8 Tran D P, Spierings EL. Headache and insomnia: their relation reviewed. Cranio. 2013;31(3):165-70.	Summarize the current scientific literature concerning the nature of the headache-insomnia relationship.	Headache is more associated with insomnia than vice versa. The association between insomnia and headache is more common in severe insomnia.	Insomnia is a risk factor for headache. Patients with TTH and migraine should be routinely evaluated for insomnia.
Engstrom et al.⁴⁷47 Engstrom M, Hagen K, Bjork M, Gravdahl GB, Sand T. Sleep-related and non-sleep-related migraine: interictal sleep quality, arousals and pain thresholds. J Headache Pain. 2013;14(1):68.	Compare subjective and objective sleep quality through diaries and PSG with headache in migraine.	PSG of patients with migraine, in the inter-crisis period, shows signs of sleep deprivation although there are no objective differences in the amount of sleep.	Migraine patients show relative sleep deprivation and need more hours of sleep than controls.
Engstrom et al.⁴⁸48 Engstrom M, Hagen K, Bjork MH, Stovner LJ, Gravdahl GB, Stjern M. Sleep quality, arousal and pain thresholds in migraineurs: a blinded controlled polysomnographic study. J Headache Pain. 2013;14(1):12.	Compare subjective and objective sleep quality through diaries and PSG in patients with SM and NSM.	SM patients present migraineurs crisis during sleep or upon awakening; whereas NSM patients present crisis throughout the day. Only NSM patients show evidence of sleep deprivation in PSG.	Signs of sleep deprivation characteristic of migraine patients in the inter-crisis period are evident only for patients whose crises occur randomly during the day.
Engstrom et al.⁴⁹49 Engstrom M, Hagen K, Bjork MH, Stovner LJ, Sand T. Sleep quality and arousal in migraine and tension-type headache: the headache-sleep study. Acta Neurol Scand. 2014;129(198):47-54.	Compare subjective and objective sleep quality through diaries and PSG in SM, NSM and TTH patients.	Although the number of hours of sleep is adequate, the TTH and NSM groups have PSG with evidence of sleep deprivation.	NSM and TTH patients show greater similarity to each other as they require more hours of sleep than SM and controls. SM patients show more sleep disturbances than controls.
Walters, Hamer and Smitherman⁵⁰50 Walters AB, Hamer JD, Smitherman TA. Sleep disturbance and affective comorbidity among episodic migraineurs. Headache. 2014;54(1):116-24.	Quantify the relationships between sleep disturbances and headache-related variables in patients with episodic migraine.	Patients with episodic migraine report poorer sleep quality.	Poor sleep quality is associated with episodes of migraine and this relationship cannot be attributed exclusively to comorbidities such as depression and anxiety.
Stark and Stark⁹9 Stark CD, Stark RJ. Sleep and chronic daily headache. Curr Pain Headache Rep. 2015;19(1):468.	Evaluate the relationship between chronic headache and sleep disorders, especially OSA.	In addition to OSA, migraine may also be related to parasomnias, restless legs syndrome, daytime sleepiness, poor sleep quality, and insomnia.	There is a clear association between OSA and snoring with morning headache. OSA and chronic migraine share obesity and patent foramen ovale as possible comorbidities.
Borkum⁵¹51 Borkum JM. Migraine triggers and oxidative stress: a narrative review and synthesis. Headache. 2016;56(1):12-35	Present the available literature on the capacity of migraine triggers to generate oxidative stress in the brain.	The TRPA1 receptor, present in C-type fibers, can be activated by oxidative stress, promoting CGRP release and triggering neurogenic inflammation. Except for pericranial pain, the other common triggers of migraine, including sleep deprivation, are capable of generating oxidative stress.	Sleep deprivation is associated with depletion of reduced glutathione in the brain, so it’s capable of generating oxidative stress, triggering neurogenic inflammation and headache.
Woldeamanuel and Cowan ⁵²52 Woldeamanuel YW, Cowan RP. The impact of regular lifestyle behavior in migraine: a prevalence case–referent study. J Neurol. 2016;263(4):669-76.	Evaluate the occurrence of episodic and chronic migraine in patients who maintain and those who do not maintain a regular lifestyle.	Patients with chronic migraine had a less regular lifestyle than patients with episodic migraine.	A regular lifestyle characterized by exercise, standardized meal times, adequate hours of sleep, and hydration status prevent chronic migraine.
Kim et al.⁵³53 Kim J, Cho SJ, Kim WJ, Yang KI, Yun CH, Chu MK. Insufficient sleep is prevalent among migraineurs: a population-based study. J Headache Pain. 2017;18(1):50.	Evaluate the occurrence of insufficient sleep in three groups of subjects: without pain, with non-migraine pain, and with migraine.	Insufficient sleep is most frequent in the respective order: migraineurs, patients with non-migraine pain, and lastly, patients without pain.	The average sleep time reported was equal in all three groups, so it’s assumed that migraineurs need more hours of sleep to feel rested.
Rosenberg, Butler and Seng¹⁴14 Rosenberg L, Butler N, Seng EK. Health behaviors in episodic migraine: why behavior change matters. Curr Pain Headache Rep. 2018;22(10):65.	Analyze lifestyle habits in people with episodic migraine.	Recent studies suggest that individuals with episodic migraine have poor quality sleep that influences the frequency and severity of pain.	Episodic migraine appears to be more associated with sleep quality than with sleep duration.
Song et al.⁵⁴54 Song TJ, Yun CH, Cho SJ, Kim WJ, Yang KI, Chu MK. Short sleep duration and poor sleep quality among migraineurs: A population-based study. Cephalalgia. 2018;38(5): 855-64.	Correlate the frequency and intensity of migraine episodes with the duration and quality of sleep.	Headache intensity is similar in migraineurs who sleep < 6 h or > 6 h. However, in migraineurs who sleep < 6 h, there is a higher frequency of episodes.	Short self-reported sleep duration (< 6 h) is associated with an increase in headache frequency.
Bertisch et al.⁵⁵55 Bertisch SM, Li W, Buettner C, Mostofsky E, Rueschman M, Kaplan ER et al. Nightly sleep duration, fragmentation, and quality and daily risk of migraine. Neurology. 2020;94(5):489-96.	Temporally correlate sleep quality with migraine attacks.	Low sleep efficiency is related to a higher risk of headache on the second day after the evaluated night.	Low sleep efficiency appears to increase the risk of migraine onset from 48 hours following the period of compromised
Navarro-Pérez et al.⁵⁶56 Navarro-Pérez M P, Suller-Marti A, Bellosta-Diago E, Roche-Bueno JC, Santos-Lasaosa S. Impact of 24-hour on-call shifts on headache in medical residents: a cohort study. Headache. 2020;60(7):1427-31.	Evaluate the effect of 24-hour oncall shifts on disability caused by headache.	Among doctors with migraine, disability increased from little or none to moderate disability after six months, along with worsening depressive and anxious symptoms.	It’s not possible to conclude whether the increase in headache disability is due to sleep deprivation or to worsening depressive and anxious symptoms.

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[1] Correspondence to: Departamento de Fisiologia e Farmacologia Instituto Biomédico - Universidade Federal Fluminense R. Prof. Hernani Pires de Mello, 101 - São Domingos 24210-130 Niterói, RJ, Brasil. E-mail: tania_thomaz@id.uff.br, tania.g.thomaz@gmail.com

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Migraine and sleep deprivation: integrative review

ABSTRACT

BACKGROUND AND OBJECTIVES:

CONTENTS:

CONCLUSION: