Sleeping with a migraine

  1. Curb stress. Smart ways to do so include:

Breathing exercises. Sit or lie down with your eyes closed. Take several long, slow, deep breaths. Get your lungs to fill and your belly to rise. Then breathe out slowly, and repeat.

Meditation. This is simply turning your attention to your breath, a word, an image, or something else that you choose to focus on. Other thoughts will come up. That’s OK. Try not to get wrapped up in them. Just let them go.

It’s not about being a mellow person or following any particular faith. And it doesn’t matter what type of meditation you do, Rosenberg says. They all help. Experiment and find a form that works for you.

Progressive muscle relaxation. Lie down with your eyes closed. Check in on every part of your body, starting with your toes and working up to your calves, thighs, abs, shoulders, and so on. Relax each area as you go.

  1. Medications. You can get relief from an occasional tension headache, Rosenberg says, by taking:
  • Acetaminophen
  • Aspirin (Don’t use for anyone under 19 because it raises the chances of Reye’s syndrome)
  • Caffeine (which is in some pain relievers)
  • Ibuprofen
  • Naproxen

Do you get tension headaches more than four times a month? If so, your doctor may give you a prescription to help prevent them. Medicines include antidepressants, such as amitriptyline or nortriptyline (Pamelor), or anti-seizure drugs, such as gabapentin (Neurontin) or topiramate (Topamax).

CASE 3

A 66-year old woman came to my office, noting that she was awakened at 5 am daily with a throbbing headache across her forehead. She described it as 6 out of 10 in severity. The headaches also occurred on occasion when she napped. The pain lasted two hours. She wasn’t nauseated or sensitive to lights during these attacks and had no history of migraine. Her neurological examination and a CT scan of the head were normal.

Some rarer headache syndromes are specifically related to sleep. Hypnic headaches, which this patient had, present generally in the elderly, and more commonly in women than men. People with hypnic headache often wake nightly with a generalized throbbing headache. Various medications, including lithium carbonate and caffeine, can actually prevent these attacks.

CASE 4
A 72-year-old woman came to my office with attacks that woke her out of a sound sleep at 3:00 am and 4:30 am every morning. She described the attacks as a loud explosion in her head. She was very frightened by these spells, but actually denied having any head pain.

This odd and rare syndrome is called exploding head syndrome. It is not actually a pain disorder, but rather a sleep disorder, although individuals may seek help at a headache center. They complain of an explosive sound in the head each night that is loud and frightening. This syndrome is often treated with clomipramine.

Many other neurological and medical illnesses can be associated with headaches and sleep, and these often have very different mechanisms and treatments. There are various sleep disturbances, for example, that can contribute to headaches. Sleep apnea syndrome, which is commonly associated with being overweight, snoring at night, and being tired throughout that day, can also be associated with headaches. The mechanism for this relationship is not entirely understood, but when this syndrome is identified and treated, chronic headaches may significantly diminish.

Another common sleep disorder is restless legs syndrome (RLS). Individuals with RLS have an uncomfortable sensation that they need to move their legs, particularly at night. As a result, they may suffer from fragmented sleep, which can lead to a worsening of a headache problem.

Finally, individuals with painful medical illnesses such as fibromyalgia often complain of aching pain in the front of the head, which is perhaps a manifestation of impaired sleep. Anxiety and depression, often associated with problems in falling asleep or staying asleep, are also commonly associated with a similar head pain.

Headache from Lack of Sleep? Here’s What to Do

If you do get a tension or migraine headache from a lack of sleep, seeking treatment right away can help reduce its duration and severity.

Tension headache treatment

Both over-the-counter (OTC) and prescription medications can reduce discomfort when a tension headache strikes. These include:

  • pain relievers such as aspirin (Bufferin), ibuprofen (Advil), and naproxen (Aleve), among others
  • combination medications that contain a pain reliever and a sedative, which are often marked with “PM” or “nighttime” on the packaging
  • triptans, which are prescription drugs used to treat migraines

To prevent recurring tension headaches, your doctor might prescribe the following:

  • tricyclic antidepressants like amitriptyline (Elavil) and protriptyline (Vivactil)
  • other antidepressants such as venlafaxine and mirtazapine (Remeron, Remeron Soltab)
  • anticonvulsants like topiramate (Topamax) and muscle relaxants

Migraine headache treatment

Migraine headaches tend to be more severe than tension headaches, so treatment is a little more aggressive. If you have a migraine, the following prescription and OTC medications may alleviate your symptoms:

  • Pain relievers such as aspirin (Bufferin), acetaminophen (Tylenol), ibuprofen (Advil), and naproxen (Aleve) may ease mild migraine pain. Medications that are specifically designed for migraines combine caffeine with aspirin, such as Excedrin Migraine, and may be helpful for moderate migraines.
  • Indomethacin can relieve migraine pain and is available as a suppository, which can be helpful if you’re too nauseous to take oral medication.
  • Triptans can help block pain pathways in the brain. They do this by binding to serotonin receptors, decreasing blood vessel swelling. This type of medication is available as a prescription pill, nasal spray, and injection. Treximet, a single-tablet dose of triptan and naproxen, is very effective at reducing migraine symptoms in most people.
  • Ergots are a type of medication containing the drug ergotamine and are often combined with caffeine. This combination eases pain by constricting blood vessels. They are effective at reducing migraine pain lasting for more than 48 hours and are most effective when taken right after symptoms begin. Dihydroergotamine (Migranal) is a type of ergot medication that tends to have fewer side effects than ergotamine.
  • Anti-nausea medications such as chlorpromazine (Thorazine), metoclopramide (Reglan), and prochlorperazine (Compazine) can help.
  • Opioid medications, including those that contain narcotics like codeine, are often used to treat migraine pain in people who can’t take triptans or ergots. These medications tend to be habit-forming and aren’t recommended for long-term use.
  • Glucocorticoids such as prednisone and dexamethasone can provide some pain relief.

The following medications may prevent headaches in people who have migraines that last 12 or more hours four or more times a month:

  • Beta-blockers, which decrease the effects of stress hormones in the body, can prevent migraines.
  • Calcium channel blockers, often used to treat high blood pressure, may prevent migraines that cause vision problems.
  • Another medication often prescribed for high blood pressure, lisinopril (Prinivil, Zestril) may reduce the length and intensity of migraine headaches.
  • The tricyclic antidepressant amitriptyline can prevent migraines, and another depression medication called venlafaxine may also reduce migraine frequency.
  • Anti-seizure drugs may reduce migraine frequency.
  • Injections of Botox into areas of the forehead and neck may help treat chronic migraines in adults. These injections may need to be repeated in three months.
  • Erenumab-aooe (Aimovig) blocks the activity of a specific type of molecule involved in causing migraines. This medication can be injected once a month to help reduce migraines.

Migraines and Sleep

According to the American Migraine Foundation, migraine sufferers are 2 to 8 times likelier to experience sleep problems. The worse the migraines, the worse the sleep problems.

The largest barriers to relief often involve insomnia and resulting sleep deprivation. It’s impossible to do anything when you’re in the midst of a migraine, including sleep. As a result, people with migraines can have a tougher time going to bed due to a late night migraine. In the long-term this can lead to chronic sleep deprivation, which has a host of mental, emotional, and physical health problems of its own, including being a trigger for migraines.

Another common migraine trigger besides sleep loss? Oversleeping to try to make up for it. Sudden changes to your sleep schedule, like jet lag, can also trigger migraines.

Common sleep disorders associated with migraines include insomnia and obstructive sleep apnea, and to a lesser extent, restless legs syndrome, excessive daytime sleepiness, and sleep bruxism.

Insomnia

Insomnia describes difficulty falling or staying asleep. People with insomnia typically spend fewer than 6 hours asleep on average, which is significantly below the recommended 7 to 9 hours for adults.

As a result, insomniacs are sleep deprived. They feel irritable during the day, tired and unfocused, and may develop depression or anxiety. These conditions create a stressful daily life, and stress itself is a headache trigger.

Over a third of people with migraines report getting only 6 hours of sleep on average per night. Problematically, shorter sleepers (those who sleep 6 hours or less) are more likely to have more frequent and severe migraines, as well as morning headaches. In another study, 80% of participants with migraines reported feeling tired upon waking up.

There is a clear correlation between lack of sleep and incidence of migraines:

Snoring and sleep apnea

Snoring and obstructive sleep apnea (OSA) have both been linked with migraines. Children with migraines are twice as likely as other children to have sleep apnea, and experience more sleep disturbances.

Snoring is noisy breathing during sleep. OSA is a more serious form of sleep-disordered breathing where the individual literally stops breathing momentarily during sleep, typically due to a blockage or narrowing of their airways. While all snorers do not eventually develop sleep apnea, it is a first warning sign, and both contribute to the kind of less restful sleep that eventually becomes sleep deprivation, which triggers migraines.

Awakening headaches

Nearly half of migraines are known as “awakening headache” since they occur between 4 and 9am in the morning. 71% of migraine sufferers experience this type of headache.

When this happens on a regular basis, it’s often a sign of a sleep disorder.

Hypnic headaches

Hypnic headaches, also known as “alarm clock” headaches, are a rare type of headache disorder that affects older adults 50 and above. The pain is significant enough to wake the person up, and can last up to 3 hours after waking.

To be diagnosed as hypnic headache, the headaches must occur at a consistent time each night, typically between 1 to 3 am, and the person must experience them at least 10 days per month. Doctors suspect hypnic headache takes place during REM sleep.

Hypnic headaches are distinct from awakening headaches as well as migraines triggered by sleep apnea.

Diagnosing migraine-related sleep disorders

If you’re concerned your migraines are related to a sleep disorder, review the following questions. If you answer yes to more than one, it may be time to talk to your doctor:

  • Do you wake up regularly with headaches?
  • Do you often feel tired during the day, even when you think you’re getting enough sleep?
  • Do you feel depressed or irritable?
  • Are you having trouble focusing during the day?

Your doctor will ask you additional questions. If they believe you may have a sleep disorder like sleep apnea, they will refer you to an overnight sleep lab for observation. There, a sleep technician will monitor your breathing, brain waves, and more while you sleep. In the days following your exam, a doctor certified in sleep medicine will analyze your results for signs of a sleep disorder.

Sleep Disorders and Headache

Cluster Headache

Cluster headaches are another primary headache that may develop during sleep. These excruciatingly severe attacks often develop within an hour of falling asleep. The pain tends to be most severe in, around or behind one eye; last 20 minutes to 3 hours; and are associated with drooping of that eyelid, redness or tearing of the eye, or running or stuffiness of the nostril on the side of the pain.

The Link Between Sleep, Headache and Mood

The same brain regions and chemical messengers impact sleep, headache and mood, so inadequate or poor quality sleep increases the odds for headache and mood change. For example, people living with migraine who also experience insomnia often suffer from anxiety or depression, which are also common migraine comorbidities. An effective migraine treatment plan would factor in the patient’s medical history and psychological factors.

The Importance of Healthy Sleep

Behavioral sleep changes can promote restful, regular sleep and reduce headache. Simple changes like establishing consistent sleep and wake-up times, as well as getting between 7 and 8 hours of sleep a day, can make a world of difference. Experts also recommend avoiding substances that impair sleep, like caffeine, nicotine and alcohol, and also suggest winding down before bed to prevent sleep problems. To hear about how members of our community stick to healthy sleep habits, read this article from our resource library.

From comorbidities to daily habits, many factors explain why a wide variety of sleep events trigger headache. Understanding your migraine and identifying simple lifestyle changes can make all the difference. As you embark on this journey, find the resources and support you need through our doctor-verified resource library and migraine support group.

Additional Resources

National Sleep Foundation
American Academy of Sleep Medicine
American Sleep Apnea Association

This article was last updated April 8, 2019.

PMC

DISCUSSION

In this study, we found that quality of sleep was associated with migraine frequency, comparing 4 migraine groups differentiated based on the number of days with migraine per month and an age- and gender-matched healthy control group. The PSQI total score was strongly associated with migraine frequency after adjustment for well-known confounding factors, such as gender, age, BMI, education level, smoking status, alcohol consumption, coffee consumption, RLS screening scores, BDI score, HADS anxiety score, and HADS depression score. Moreover, sleep quality (as indicated by the PSQI) correlated strongly with migraine frequency regardless of whether patients had migraine with aura or without aura. Overall, PSQI total scores were highest for the high and chronic frequency groups (i.e., ≥8 days/month of migraine headaches), and sleep quality was poorest in subjects with chronic migraine. In addition, these patients most often reported sleep disturbances related to the PSQI items “cannot get to sleep within 30 minutes,” “wake up in the middle of the night or early morning,” “bad dreams,” and “pain.”

According to the IHS classification and ICHD-III beta criteria, migraine can be classified as chronic migraine (attacks on ≥15 days/month and for >3 months) or episodic migraine (others that do not fulfill the criteria for chronic migraine).18 A previous study divided migraineurs into 3 subgroups based on the number of days with migraine attacks per month (1–4 days/month, 5–7 days/month, ≥8 days/month). The authors found that sleep quality was particularly poor in patients with 8 or more migraine days per month.7 However, the possible relationship between sleep quality and more detailed differentiation of migraine frequency (such as 9–14 days/month, ≥15 days/month) remained uncertain. Therefore, we designed this study comparing 4 migraine groups with more detailed differentiation based on the number of days with migraine per month and an age- and gender-matched healthy control group to investigate the relationship between migraine frequency and sleep quality. Indeed, our study demonstrates subgroup differences and correlations in migraine frequency and sleep quality.

Unlike previous studies in the literature, our study had a control group and 4 migraine subgroups differentiated according to migraine frequency. Our study was designed in consideration of anxiety, depression, and RLS as potential confounding factors. Similar to our results, Seidel and colleagues 7 found that PSQI scores and poor subjective quality of sleep were higher in migraineurs than in controls. Additionally, our study revealed that migraineurs’ sleep disturbances are attributed to “go to sleep within 30 minutes,” “wake up in the middle of the night or early morning,” and “bad dreams.” Consistent with our findings, Karthik et al found a high prevalence of poor sleepers among patients with “migraine without aura,” who reported difficulty in sleep initiation, sleep maintenance, and early morning waking.9 Furthermore, our subgroup of migraine with aura also had similar findings.

Kelman and Reins4 found that migraineurs have difficulty staying sleep and are prone to waking up with headaches (71% of migraineurs) early in the morning. Similarly, the migraine group subjects in our study reported “wake up in the middle of the night or early morning.”

Migraine has many comorbid disorders, the most common of which are depression and anxiety, which have been reported to occur in 63.8% and 60.4% of migraine patients, respectively.24 Here, we found that high BDI, HADS anxiety, and HADS depression scores were associated with higher migraine frequency (linear trends). Schürks et al showed that RLS prevalence in migraine ranged from 8.7% to 39.0% and identified RLS as an important comorbidity of migraine.25 Additionally, results from a prior systematic review and a recent longitudinal cohort study suggest that migraine is associated with an increased probability of RLS.25,26 Similarly, we observed a strong positive association between RLS screening score and greater migraine frequency. Hence, our findings support the notion that migraine frequency correlates with anxiety, depression, and the possibility of RLS.

In our study, smokers, alcohol drinkers, and coffee drinkers tended to have higher migraine frequency, consistent with a previous study.27 These findings are consistent with the possibility that smoking, alcohol consumption, and coffee consumption may be important triggers of migraine attacks. Additionally, in this study, high percentages of nonsmokers and nondrinkers were found; this may be due to cultural differences.28 Our univariate factor analysis indicated that subjects with medium, high, and chronic migraine frequency were more likely to have poor sleep quality than control subjects. Meanwhile, high RLS screening scores, BDI, HADS anxiety, and HADS depression scores also correlated with a higher prevalence of poor sleep quality. Subsequent multivariate factor analysis indicated that high migraine frequency and RLS are independent predictors of poor sleep quality after adjusting for baseline characteristics.

Sleep and migraine may link in a bidirectional way and share some pathophysiological mechanisms. First, regarding the mechanism of impact of sleep disturbances on headache, previous experimental studies have shown that sleep deprivation increases self-reported pain.29 Additionally, sleep deprivation may lead to a disturbance of the descending pain inhibitory control system.30,31 In addition, deficiency of serotonin descending pain inhibitory was suggested to be associated with migraine pathophysiology.32 Second, regarding the mechanism of impact of headaches on sleep, chronic pain may lead to alterations of neuron activity in the raphe magnus, which can regulate the sleep cycle.33 Therefore, this type of alteration may have an influence on sleep. Third, migraine and sleep disorders may share some pathophysiological mechanisms. The pathophysiology of migraine includes cortical spreading depression, activation and sensitization of the trigeminovascular system, and excitatory-inhibitory imbalance of the dura, brainstem, cortex, and subcortical regions.34–36 Furthermore, a prior review suggested that the hypothalamic orexinergic system plays a role in the association between sleep and the development of a migraine headache.37 Orexin-containing neurons in the hypothalamus fire in wakeful states, and disruption of orexinergic signaling results in excessive sleepiness. Orexinergic cells affect not only monoaminergic activity across the sleep cycle, but also pain modulation. Meanwhile, orexin may affect trigeminovascular tone. Furthermore, migraine attacks can be triggered by stress, fatigue, sleep deprivation, or poor sleep habits, which activate the hypothalamus and orexin system simultaneously. The pineal gland synthesizes and secretes melatonin, which is stimulated by darkness and inhibited by light in a 24-hour circadian pattern.38 Low urinary melatonin and 6-sulfatoxymelatonin levels have been associated with migraine.39,40 The melatonin level may not only play a role in the pathophysiology of migraine, but may also predispose people to awakening from rapid eye movement (REM) sleep with a headache.41 Collectively, these evidences suggest a bidirectional relationship between sleep and migraine and sharing of some pathophysiological mechanisms.

Interestingly, the high subscores for the PSQI items “cannot get to sleep within 30 minutes,” “wake up in the middle of the night or early morning,” and “bad dreams” in our higher migraine frequency groups may be related to the fact that dreams, including nightmares, occur during REM sleep. Hsu et al found that waking up with a migraine attack occurred most often during REM sleep.42 Indeed, REM sleep disruption is suggested to be an underlying mechanism of bad dreams, untimely waking, and nocturnal migraine attacks.13,43,44 Our findings are in agreement with Vgontzas et al45 who reported 48.8% of migraineurs complain of sleeping difficulties. In this study, many of the patients would “wake up in the middle of the night or early morning.” A previous study found that most patients with hypnic headaches have a history of migraine or coexisting migraine.46 Additionally, it has been reported that migraine is a sleep-related headache and that migraine-related symptoms may disturb sleep quality. In our study, although we carefully ruled out the presence of hypnic headache, “Waking up in the middle of the night or early morning” may be one of the sleep-related symptoms of migraine. Further studies are needed to verify this hypothesis.

In the present study, we found that sleep quality was associated with migraine frequency in adults. It has been also reported that migraine may lead to nonrapid eye movement (NREM) parasomnias and sleep-related movement disorders in children.47 Furthermore, previous studies showed that migraine may disturb sleep architecture, with excessive daytime sleepiness, higher prevalence of cosleeping with family, and disorders in initiating and maintaining sleep in developmental age.48–52 Additionally, migraines may have some impacts on perceptual organizational ability,53 mood,54 and motor coordination55 in school-aged children. Collectively, the interrelationship and influences between migraine and sleep may not only occur in adults but also in adolescents and children.

The strengths of this study are the controlled study design, the large number of subjects, the differentiated subgroups, the use of validated questionnaires, our consideration of comorbid anxiety, depression and restless leg syndrome, our analysis of migraine subgroups (with or without aura), the similarity of the study groups regarding demographics, and our robust statistical analysis.

Notwithstanding, several limitations of the study must be taken into consideration. First, we used a cross-sectional design, which restricts the causal inference between migraine and sleep quality. Second, our study population consists of patients who visited the Tri-service General Hospital outpatient department, thereby limiting the broad generalizability of the findings. Third, subjective sleep quality and habits were evaluated with the self-rated PSQI scoring system; we did not measure sleep with an objective assessment. Regarding, PSQI scores, it should also be mentioned that the mean PSQI score for the control group was 7.0 ± 3.4 (poor sleepers, 63.4%), which is higher than that from a previous cross-sectional study in Austria7, but similar to data obtained for premenopausal women in Taiwan (6.1 ± 2.2; poor sleepers, 60.8%).56 It could be that PSQI scores differ between Asian and European subjects. Fourth, the RLS screening score in Table ​Table11 can only suggest the probability of an RLS diagnosis rather than RLS severity. Further studies are warranted with use of the IRLS to clarify the relationship between RLS severity and sleep quality among migraineurs.57 Fifth, migraines often present with prodromal symptoms including sleepiness and postdromal symptoms including fatigue.58,59 This would potentially confound the outcome in this study. However, these detailed prodrome or postdrome symptoms were unavailable in this study. Further studies are warranted to establish the potential relationship between premonitory/ postdromal symptoms and sleep quality. Lastly, the chronic frequency group was relatively small. A future study for recruitment of more chronic migraine patients is warranted.

In conclusion, poor sleep quality and a higher prevalence of poor sleepers are associated with greater migraine frequency regardless of auras. High migraine frequency and RLS emerged as independent factors of poor sleep quality. These findings may have clinical implications. In particular, pharmacological episodic migraine prevention may reduce the tendency for migraine sufferers to become poor sleepers.

CAN LACK OF SLEEP CAUSE HEADACHES?

A good night’s sleep keeps us healthy and happy, and for headache sufferers, it’s particularly important. Irregular sleep patterns may trigger headaches in some and changes in sleep patterns may trigger migraines in some.

The between headaches and sleep has been known for decades, but what isn’t clear is whether headaches cause disrupted sleep or whether headaches are a result of irregular sleep patterns. 1 (It’s a classic chicken-or-egg situation). Generally, a lack of sleep is known to trigger headaches and migraines in some people. 2 In a large study of migraine sufferers, half said sleep disturbances contributed to their headaches. And those who slept only six hours a night on average had more frequent and more severe headaches than those who slept longer. 3

But the opposite is also true. Too much sleep can trigger headaches as well – particularly migraines and tension-type headaches 4

In addition to irregular sleep patterns, sleep disorders and headaches are linked. In fact, sleep disorders like sleep apnea, insomnia and circadian rhythm disorder are disproportionately observed in people with headache diagnoses, including migraines and tension-type headaches. 5

Although the relationship between headaches and sleep is complex and more studies are needed to fully understand it, it is thought that a part of your brain important for sleep called the hypothalamus could be involved in some headaches. 6 For example, two types of rare headaches are inherently linked to sleep: cluster headaches and hypnic headaches. 7 8 9

Worried you suffer from a sleep disorder? Be sure to consult with your doctor. There is evidence that treating a sleep disorder can help reduce the burden of headaches in some people. Modifying your sleeping habits could also potentially help you manage your headaches. In one small study, women who underwent behavioral therapy such as instituting a consistent sleep schedule and eliminating TV in bed, had fewer and less intense migraines.

Learn more about good sleep habits and tips for better sleep that you can try tonight on Excedrin.com.

Tension headaches and sleep posture: Is there a link?

What are tension headaches?

Tension headaches (also known as tension-type headaches) are the most common type of headache. According to the international classification of headache disorders, they are classified as a ‘primary headache’ (1). They occur when neck or scalp muscles are tense, or they contract. Whilst the cause of many headaches remains a matter of debate, the most common causal factors behind them are believed to be anxiety, stress, depression, and head trauma (2). Tension headaches are commonly misdiagnosed as migraines.

What are the most common treatment options?

Most people with tension headaches manage with over the counter medications such as paracetamol and ibuprofen. Non-steroidal anti-inflammatory drugs (NSAIDs), which includes ibuprofen, naproxen and ketoprofen are commonly used (3), as are aspirin in people over 16 years of age. The majority of tension headaches are episodic. Where headaches are chronic, tricyclic antidepressants such as amitriptyline have been shown to have a positive impact on alleviating pain and the incidence of future headaches (4). Proponalol, a beta blocker, has also been used to treat tension headaches. However, there is no significant evidence of their effectiveness and they are now rarely used as a result (5). For non-pharmaceutical treatment methods, there is mixed evidence regarding the use of both acupuncture and osteopathy in the management of chronic tension headaches (6,7).

Can someone reduce the severity and/or frequency of headaches by improving their sleep position?

Recently, there has been a focus on the role of sleep and sleeping patterns in regards to the onset of tension headaches. It is well established that there is a direct relationship between sleep and tension headaches: irregular sleep can trigger episodic headaches, with sleep disorders such as insomnia and sleep apnoea also playing a significant part in exacerbating such episodes (8). However, research into sleep position and its relationship with headaches is a relatively new field that requires some further attention. Many guidelines offer some kind of instruction on sleeping position. This usually involves recommendations to use a different pillow or change sleeping positions, based on assumption that many headaches have some form of relation to the posture of the neck and back. However, it is not clear what the evidential basis for many of these recommendations is, and there is not a sufficient body of evidence from which to draw conclusion. Of the studies that do exist, much has been focused on posture, spinal manipulation and soft tissue therapy. Much of this literature has focused on the role of chiropractic manipulation for tension headache, although a systematic review conducted in 2006 found no conclusive evidence for the role of chiropractic therapy in improving posture (9). Much of the sleep literature focuses on other areas, such as teeth grinding, the relationship of tension headaches with co-morbidities such as mental health disorders, and tension headaches as a secondary development of existing sleep disorders. There is almost no formal literature on the role of sleep posture in the reduction of headaches. There is however a significant body of work on the role of posture and sleep hygiene for established sleep disorders (10). This makes it very difficult to formally evaluate the role of body posture in reducing tension headaches. Of the limited literature that does exist, a comprehensive study of the prevalence and risk factors of morning headaches in the general population, undertaken by the Stanford University Sleep Research Centre in 2004, does not even consider sleep posture (or the position of the head and neck) as a modifiable risk factor. This is not to say that the study does not recognise the role of good sleep hygiene in preventing headaches, but it does not hypothesise that posture is a significant contributor to tension headaches either. The study cohort, consisting of almost 20,000 participants, was drawn from a wide cross section of society in the United Kingdom, Portugal, Spain, Germany and Italy. The main causes of morning headaches were identified as co-morbidity with anxiety and depressive disorders (29%), major depressive disorder alone (21%), non-specified dyssomnia (17%), insomnia (14%) and circadian rhythm disorder (19%). Other contributory factors to headaches identified in a systematic literature review within the study were sleep-related breathing disorders, hypertension, musculoskeletal diseases, the use of anxiolytic medication and heavy alcohol consumption (11). The study also concluded that morning headaches affected 1 in 13 of the general population. A study outlining the epidemiology of concurrent headache and sleep problems in Denmark, with a total of almost 130,000 randomly selected participants, also found that the main risk factors were harmful lifestyles, depressive disorder and the presence of stress (12). However, the questionnaire used by the study did not ask any questions regarding posture, or sleeping position. It should be noted that lack of evidence does not necessarily equate to lack of effect in regards to posture and sleep, and there is a clear need for this particular area of research to be better developed. Much of the current evidence supporting a certain sleep position is low down the hierarchy of evidence – ideas, editorials, opinions and case study observations are far more prominent than rigorously conducted, well designed trials in providing support for this theory. Of the commentary that does exist, the majority of it focuses on the negative side effects of sleeping in the foetal position – something that 75% of most adults do on a regular basis. Again, it is not clear what the evidence for this assertion is. Future studies that survey large populations regarding tension headaches could develop their understanding of this particular research area by incorporating further questions on sleep posture.

  1. Diagnosis and Management of Migraine, Tension-Type, Cluster and Medication-Overuse Headache. British Association for the Study of Headache (BASH) Guidelines (2010)
  2. National Institute of Care Excellent Clinical Knowledge Summary (CKS). Headache : tension-type. November 2012. Available online at http://cks.nice.org.uk/headache-tension-type (last accessed 4th January 2014)
  3. Pini LA, Del Bene E, Zanchin G, Sarchielli P et al. (2008). Tolerability and efficacy of a combination of paracetamol and caffeine in the treatment of tension-type headache: a randomised, double-blind, double-dummy, cross-over study versus placebo and naproxen sodium. J Headache Pain 9(6):367-73
  4. Jackson JL, Shimeall W, Sessums L et al. (2010). Tricyclic antidepressants and headaches: systematic review and meta-analysis. BMJ 341:c5222
  5. Verhagen AP, Damen L, Berger MY, Passchier J, Koes BW. (2010). Lack of benefit for prophylactic drugs of tension-type headaches in adults: a systematic review. Fam Pract 27(2):151-65
  6. Melchart D, Streng A, Hoppe A et al. (2005). Acupuncture in patients with tension-type headache: randomised controlled trial. BMJ 13:331(7513):376-82
  7. Anderson RE, Seniscal C. (2006). A comparison of selected osteopathic treatment and relaxation for tension-type headaches. Headache 46(8):1273-80
  8. Rains JC, Davis RE, Smitherman TA. (2014). Tension type headache and sleep. Curr Neurol Neurosci Rep 15(2):520
  9. Ernst E, Canter PH. (2006). A systematic review of systematic reviews of spinal manipulation. J R Soc Med 99(4):192-6
  10. Menon A, Kumar M. (2013). Influence of body position on severity of obstructive sleep apnea: a systematic review. ISRN Otolaryngol
  11. Ohayon MM. (2004). Prevalence and risk factors of morning headaches in the general population. Arch Internal Med 12:164(1):97-102
  12. Lund N, Westergaard ML, Barloese M, Glumer C, Jensen RH. (2014). Epidemiology of concurrent headache and sleep problems in Denmark. Cephalalgia 34(10):833-45

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