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CME / ABIM MOC / CE

What Is the Effect of Sleep Quality on Migraine?

  • Authors: News Author: Megan Brooks; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 11/12/2021
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 11/12/2022
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Target Audience and Goal Statement

This activity is intended for neurologists, family medicine/primary care clinicians, internists, nurses, psychiatrists, and other members of the health care team who treat and manage patients with migraine.

The goal of this activity is to describe differences in subjective sleep quality, measured using the Pittsburgh Sleep Quality Index, and objective sleep architecture, measured using polysomnography, in adult and pediatric patients with migraine compared with healthy control patients, based on a meta-analysis.

Upon completion of this activity, participants will:

  • Assess differences in subjective sleep quality and objective sleep architecture in adult and pediatric patients with migraine compared with healthy controls, based on a meta-analysis
  • Evaluate the clinical implications of differences in subjective sleep quality and objective sleep architecture in adult and pediatric patients with migraine compared with healthy controls, based on a meta-analysis
  • Outline implications for the healthcare team


Disclosures

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Medscape, LLC encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


News Author

  • Megan Brooks

    Freelance writer, Medscape

    Disclosures

    Disclosure: Megan Brooks has disclosed no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

Editor

  • Stephanie Corder, ND, RN, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Stephanie Corder, ND, RN, CHCP, has disclosed no relevant financial relationships.

CME Reviewer/Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.

CE Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Amanda Jett, PharmD, BCACP, has disclosed no relevant financial relationships.

None of the nonfaculty planners for this educational activity have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, reselling, or distributing healthcare products used by or on patients.


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CME / ABIM MOC / CE

What Is the Effect of Sleep Quality on Migraine?

Authors: News Author: Megan Brooks; CME Author: Laurie Barclay, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

CME / ABIM MOC / CE Released: 11/12/2021

Valid for credit through: 11/12/2022

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Clinical Context

Sleep in patients with migraine is poorly understood, as sleep alterations can be a trigger, avenue for treatment, or symptom of migraine. Clarifying the profile of sleep in migraine and its relation to migraine-related disability could enable clinicians to support those with migraine and deliver effective sleep interventions.

Study Synopsis and Perspective

Patients with migraine experience greater sleep disturbance than those without the disorder, although it remains unclear whether migraines cause poor sleep or vice versa.

Results of a large meta-analysis showed that both adults and children with migraines get less nightly rapid eye movement (REM) sleep. In addition, the findings also show that children get less total sleep time than peers without these debilitating headaches.

The relationship between sleep and migraine is complex, as sleep disturbances can be a trigger, treatment, or symptom of migraine.

"Our analysis provides a clearer understanding of migraines and how they affect sleep patterns and illustrates the impact that these patterns might have on a person's ability to get a good night's sleep," Jan Hoffmann, MD, PhD, from King's College London in the United Kingdom, said in a news release.

The study was published online September 22 in Neurology.

Subjective, Objective Sleep Affected

The meta-analysis included 32 studies with more than 10,000 adults and children with and without migraine. Subjective sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI) and objective sleep architecture was measured using polysomnography.

Overall, adults with migraines had higher (worse) scores than healthy adults on the PSQI (P<.001).

"This finding is not surprising; poor sleep is reported as an exacerbating factor for migraines in 50% of cases, and the effect size was larger in chronic [migraine] patients, in line with previous research wherein poor sleep is shown to be an important factor in progression to chronic migraine," the investigators note.

Polysomnography studies revealed that adults and children with migraine had a lower percentage of REM sleep (P=.017 and P=.025, respectively) than healthy controls.

Children with migraines also had less total nightly sleep time (P=.039) and more wake time (P<.001) but took less time to fall asleep (P<.001) than their healthy peers.

The authors note that the analysis is unable to prove a causal relationship between sleep and migraines. In addition, the studies included in the analysis also did not report whether patients experienced migraine attacks during sleep itself and it was unclear whether patients were receiving medications that affect sleep cycles.

Despite these caveats, the authors suggest the need for clinicians to "prioritize sleep interventions" in patients with migraine headaches.

Chicken or the Egg Scenario

Reached for comment, Bradley V. Vaughn, MD, a neurologist and professor of sleep medicine and epilepsy at the University of North Carolina, Chapel Hill, said, "This is an extension of other work that has shown both subjective and objective sleep issues seen in patients with migraine."

"What I think we are still trying to understand is, if the sleep dysfunction is a nonspecific marker from the migraine or does the sleep dysfunction offer an avenue of treatment? As sleep is a function of the brain, we know many neurological conditions improve as we improve our sleep," said Dr Vaughn, who was not involved in the study.

Also weighing in on the analysis for Medscape Medical News, Shaheen E. Lakhan, MD, PhD, a neurologist in Newton, Massachusetts, said, "Interestingly, sleep and pain are both needed for survival and quite interrelated. This meta-analysis supports this concept."

"Migraine, as a chronic pain disorder, seems to follow the rules that the more pain one has, the greater the sleep disturbance--subjective and objective," Dr Lakhan said.

"The relationship works both ways too in the classic 'chicken or egg' conundrum. Disturbances in sleep may precede chronic pain or are generated or worsened by pain. This phenomenon is mediated largely by changes to the neuroendocrine and inflammatory systems," he explained.

"What is becoming clearer every year [is this]: Forget the 'apple a day [keeps the doctor away].' Whether you have migraines or not, a good night's rest is exactly what the doctor ordered," Dr Lakhan said.

The study was supported by the Medical Research Council and the Migraine Trust in the UK. Dr Hoffmann, Dr Vaughn, and Dr Lakhan have disclosed no relevant financial relationships.

Neurology. Published online September 22, 2021.[1]

Study Highlights

  • This random effects model meta-analysis involved a systematic search of 5 databases (Embase, MEDLINE, Global Health, APA PsycINFO, APA PsycArticles) through December 17, 2020, for case-controlled studies measuring PSG and/or PSQI in patients with migraine.
  • Exclusion criteria were other headache disorders and pregnancy.
  • Of 32 eligible studies, 21 measured PSQI and MIDAS in adults; 6 measured PSG in adults and 5 in children.
  • Overall mean study quality score was 5 of 9, which did not moderate any results, and there was no risk for publication bias.
  • Adults with migraine had higher PSQI scores than healthy controls (g=0.75; P<.001; 95% confidence interval [CI], 0.54-0.96), with greater effect in chronic vs episodic migraine (g=1.03 [P<.001; 95% CI, 0.37-1.01]; g=0.63 [P<.001; 95% CI, 0.38-0.88], respectively).
  • There was no significant overall correlation between PSQI and MIDAS scores in people with migraine.
  • On PSG, adults and children with migraine had a lower percentage than controls of REM sleep (g=0.22 [P=.017; 95% CI, 0.41, 0.04]; g=0.71 [P=.025; 95% CI, 1.34, 0.10], respectively).
  • Compared with controls, children, but not adults, with migraine had less total sleep time (g=1.37; P=.039; 95% CI, 2.66, 0.10), more wake time (g=0.52; P<.001; 95% CI, 0.08, 0.79), and shorter sleep onset latency (g=0.37; P<.001; 95% CI, 0.54, 0.21).
  • The investigators concluded that people with migraine have significantly poorer subjective sleep quality, more so in chronic migraine, and more altered sleep architecture than healthy individuals.
  • Poor subjective sleep quality is not surprising, as poor sleep has been reported as an exacerbating factor for migraines in half of cases.
  • Adults and children had significantly less REM sleep than controls, and children also had significantly reduced sleep time, shorter sleep onset, and more wake time than controls.
  • Previously reported associations between migraine and REM sleep have included reduced REM sleep the night before a migraine attack and cutaneous allodynia, which is prominent during migraine attacks, worsening after REM sleep deprivation.
  • These observations suggest possible dysfunction in mechanisms underlying REM-non-REM or REM-wake transitions in migraine, perhaps via the hypothalamic orexinergic system essential in stabilizing sleep/wake transitions and REM sleep and linked to migraine.
  • Shorter sleep onset in children with migraine than in controls suggests that they may be operating at higher sleep pressure because of chronic sleep deprivation, perhaps from headache and/or behavior.
  • Alternatively, children with migraine may be biologically sleepier than their healthy peers.
  • However, the interplay between migraine and sleep is likely complex and still poorly understood.
  • Nonetheless, this meta-analysis highlights the importance of assessing and treating sleep as an integrated part of migraine management.
  • Clinicians should prioritize sleep interventions and consider sleep quality when prescribing medication, particularly as recent studies have shown that sleep interventions are useful in reverting chronic to episodic migraine.
  • This meta-analysis also shows the limitations of drawing conclusions from a small number of case-controlled PSG studies because of significant confounding and heterogeneity.
  • As the meta-analysis could not prove causation, the investigators recommend further longitudinal empirical studies to clarify this relationship on a larger scale, using standardized, population-based approaches to sleep architecture to minimize variability.
  • Study limitations include inability to determine whether patients on medication were excluded, but when this was included as a moderator, studies that excluded those on medications had a smaller effect size for total sleep time.
  • In addition, the studies did not report whether patients experienced attacks during sleep itself, despite two thirds of patients with migraine reporting this.

Clinical Implications

  • People with migraine have significantly poorer subjective sleep quality and more altered sleep architecture than healthy individuals.
  • As the meta-analysis could not prove causation, the investigators recommend further longitudinal empirical studies.
  • Implications for the Health Care Team: Members of the healthcare team should prioritize sleep interventions and consider sleep quality when discussing or providing education on possible medications.

 

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