Migraine and sleep disorders: a systematic review

Abstract

Migraine and sleep disorders are common and often burdensome chronic conditions with a high prevalence in the general population, and with considerable socio-economic impact and costs.The existence of a relationship between migraine and sleep disorders has been recognized from centuries by clinicians and epidemiological studies. Nevertheless, the exact nature of this association, the underlying mechanisms and interactions are complex and not completely understood. Recent biochemical and functional imaging studies identified central nervous system structures and neurotransmitters involved in the pathophysiology of migraine and also important for the regulation of normal sleep architecture, suggesting a possible causative role, in the pathogenesis of both disorders, of a dysregulation in these common nervous system pathways.This systematic review summarizes the existing data on migraine and sleep disorders with the aim to evaluate the existence of a causal relationship and to assess the presence of influencing factors. The identification of specific sleep disorders associated with migraine should induce clinicians to systematically assess their presence in migraine patients and to adopt combined treatment strategies.

Keywords: Circadian rhythm sleep-wake disorders; Headache; Insomnia; Migraine; Narcolepsy; Parasomnias; Periodic limb movement disorder; Restless leg syndrome; Sleep apnea; Sleep disorders.

Fig. 1

Key structures involved in migraine and sleep-wake regulation

Fig. 2

Interaction between migraine and insomnia. Available evidence suggests the existence of a bidirectional association between migraine and insomnia that is independent from anxiety and depression. Migraine patients are at increased risk of developing insomnia, and insomnia is a risk factor for migraine onset and for increased migraine impact, pain intensity, and chronification. Routine evaluation of the presence of insomnia complaints in patients with migraine and implementation of specific pharmacological and non-pharmacological insomnia treatments would be appropriate since a reduction of migraine burden might be observed

Fig. 3

Interaction between migraine and obstructive sleep apnea. Although available studies failed to find a causal relationship between obstructive sleep apnea (OSA) and migraine, little evidence suggests that OSA may be a trigger of migraine in selected patients and facilitate migraine progression. For this reason it would be reasonable check for the presence of signs or symptoms attributable to OSA in migraine patients, especially in those reporting morning headache, habitual snoring, apnea episodes during sleep, obesity, craniofacial morphology and oral anatomy, neuromuscular disorders, and substances use. Clinicians should screen and select patients to be studied with polysomnography upon suspicion of sleep-related breathing disorder. Patients with OSA diagnosis should receive the guideline recommended treatments. Since available evidence suggests that obesity is a major risk factor for OSA development and progression and for migraine chronification, appraisal of a normal weight (body mass index=18.5-24.9 Kg/m²) should be strongly encouraged in patients with comorbid OSA and migraine since an improvement of both OSA severity and migraine frequency might be expected

Fig. 4

Interaction between migraine and restless legs syndrome. Available evidence suggests the existence of a bidirectional association between migraine and restless leg syndrome (RLS). RLS in patients with migraine seems to be associated with higher migraine frequency and related disability. It would be reasonable to systematically check patients with migraine for symptoms of RLS and adopt specific RLS treatments if needed; this approach should be considered complementary to that of migraine and may lead an improvement of migraine frequency and related disability. In the decision-making process for the choice of migraine preventive treatment clinicians should consider the possible exacerbating effect of antidepressants on RLS symptoms, and their effectiveness should be balance over the possible worsening effect on RLS