Dr. Shapira's Chicago Headache Blog

An article by Jeanetta C. Rains1 and J. Steven Poceta gives an opinion paper on the relation of sleep to headache. They feel that headache is linked to a wide variety of sleep disorders that may impact treatment results and headache management.

They believe that after standard diagnosis of headache a sleep history should be collected according to headache problems. Initally they state that you should rule out sleep apnea in patients with headaches on awakening. I agree and have frequently said that the two main causes of morning headaches are TMJ disorders, Sleep Apnea and Bruxing. The NHLBI of the NIH published a report "Cardiovascular and Sleep Related Consequences of Temoporomandibular Disorders" Morning headaches can also be caused by jaw clenching but newer evidence relates clenching to awakenings by sleep disordered breathing.

They believe that cluster headaches, chronic migraine and chronic tension-type headache should have sleep apnea ruled out as a cause. I believe that looking at the neuromuscular system to evaluate patients for TMJ disorders, muscle disorders and trigeminal nervous disorders related to the bite is also essential. Neuromuscular Dentistry is a method that has been shown to be "overwhelmingly successful according to Dr Barry Cooper and as published in Cranio Journal.

If there are signs and symptoms of sleep apnea they Rx polysomnography and treatment with CPAP. While CPAP is effective I feel patients with headaches and sleep apnea would be much better served by combining treatments by utilizing an intra-oral apnea appliance that will also help decrease headaches of trigeminal orgin, or almost all types of headaches. Studies with oral appliances for headache treatment show a minimal 50% improvement in the majority of patients. They do not advocate suspending regular headache treatment when treating apnea but many of the patients treated with oral appliances report complete relief of headaches. CPAP can also be effective but 60% of patients reject it and it causes negative side effects in a significant number of patients who use it leading to discontinuation of CPAP and/or poor compliance.

The authors stated that use of oral appliance, surgery and weight loss are untested displaying a suprising amout of ignorance about the current parameters of care for treating sleep apnea that considers oral appliances to be a first line of treatment for mild to moderate sleep apnea and an alternative for severe apnea when CPAP is not tolerated. The percentage of patients that do not tolerate CPAP is the same for mild, moderate and severe sleep apnea patients.

The authors reported "patients with migraine and tension-type headache, insomnia is the most common sleep complaint, reported by one half to two thirds of clinic patients." They did not specify it is was sleep onset insomnia or maintenance of sleep insomnia.

The authors also stated "All headache patients, particularly those with episodic migraine and tension-type headaches, may benefit from inclusion of sleep variables in trigger management."

I believe it in incumbent on physicians and dentists treating headaches be acutely aware of the effect of sleep disorders on headache.

They should also be aware that psychiatric disorders and depression frequently occur in chronic pain patients as a direct result of the chronic pain.

Treatment of sleep disorders and headache with a combination of a neuromuscular daytime orthotic and a n intraoral sleep apnea appliance or use of a 24 hour orthotic is "overwhelming successful" as published in Cranio Journal.

Labels: atypical migraine, chronic daily headaches, cluster headache treatment, cluster headaches, neuromuscualr dentistry, oral appliances, SLEEP APNEA, sleep disorders, tension-type headaches

Patients with morning headaches usually have either TMJ disorders or Sleep Apnea. Sleep Apnea can be treated with CPAP or an Oral Appliance. Patients who have TM Joint clicking and are undergoing treatment for headaches or TMD can benefit in several ways from having a night-time apnea appliance and a daytime neuromuscular orthotic.

A problem that is sometimes encountered with oral appliances for sleep apnea are undesired bite changes. These changes can actually be helpful when treating TMJ clicking and popping and headaches. The bite changes that occur are actuallly the healing of the TM Joint. The jaw usually postures forward unloadding the retrodiscal lamina of the TM Joint that is compressed in patients with clicking. The retrodiscal lamina rehydrates and does not let the condyle go into retrusive pathology which serves to stabilize the disk.

The Daytime appliance allows this position to stabilize and heal. In patients who are not undergoing treatment exercises are done to prevent this healing from occuring. The joints will frequently heal if placed in a healthy position. A recent paper showed no damage to the joints with sleep appliances.

The American Academy of Sleep Medicine recommends that dentists fitting patients with oral appliances for sleep apnea be well versed in treating TMJ disorders. There are many good reasons for this recomendation. Dentists who do not uderstand how bite changes affect the joints and the muscles as well as head posture can create difficult problems they do not have the expertise to treat. Please check my I HATE CPAP website (http://www.ihatecpap.com) for more information about the dangers of sleep apnea and on how oral appliances are used in treating sleep apnea.

Labels: AASM, American Academy of Sleep Medicine, bite Changes, cluster headaches, headaches, neck pain, SLEEP APNEA, TMD, TMJ, TMJ clicking, TMJ pain, TMJ popping, TMJD

THE FOLLOWING WAS COPIED FROM THE NATIONAL SLEEP FOUNDATIONS WEBSITE:

"Treating Sleep Apnea: What's New for CPAP Masks?
For the 18 million people living with sleep apnea, under 50% regularly use their CPAP mask while sleeping at night. Common patient complaints are that the masks, which opens the upper airway with pressurized air through a tube, are uncomfortable, awkward, and claustrophobic. Rates of sleep apnea are rising in the US and many people go undiagnosed.."

The NSF foundation links to a Wall Street Journal Article on Sleep Apnea Treatment that can be found at:
http://online.wsj.com/article/SB10001424052748704107204575039101390202576.html?mod=WSJ_hpp_MIDDLENexttoWhatsNewsForth
The articl titled
"The New Face of Sleep
As Patients Balk at Bulky Masks, New Efforts to Treat Sleep Apnea" is a worthwhile read. The history of sleep apnea diagnosis and treatment starting in the 1960's. In the early days of apnea treatment cosisted of a tracheotomy. The article suggests there are 18 million patients in the US with Sleep Apnea but many experts consider that estimate to be very low. It is upsetting that the NEW York Times known for its accuracy gave an outdated dfinition of why apnea occurs. "The NY Times reported "Patients with sleep apnea stop breathing during sleep because the soft palate collapses and blocks the upper airway. A tell-tale symptom is chronic and loud snoring." This is actually incorrect. The level of the blockage is actually at the base of the tongue. It was this mistaken belief that the soft palate was the obstruction that led to countless UP3 surgeries (uvulopaltopharyngealplasty) LAUP (laser assisted uvuloplasty) and other surgeries then sometimes relieved snoring but rarely were successful in treating apnea. The tongue actually obstructs the airway and prevents the soft palate from letting air pass. The soft palate acts like a swinging door and the tounge like a door stop that doesn't let the door open. Surgery to the soft palate is like taking an axe to a door instead of removing the door stop.

The times story reports on CPAP, oral appliances (Dental Sleep Medicine), behavioral modification and surgical treatments. It even discusses the didgeridoo and quotes the British Medical Journal's study that learning circular breathing and playing the didg can reduce snoring and sleep apnea. I suggested several years ago in a Sleep and Health Journal article "Didgeridoo and Apnea Too" that medical insurance compnies should cover The didgeridoo as DME or durable Medical Equipment and pay for didgeridoolessons as respiratory therapy.

There is a picture of a "collapsed airway" in the article that is incorrect and does not show how the tounge actually occludes the airway. The article does say there is some evidence compliance is better with oral appliances. Actually 90-95% of patients prefer an oral appliance over CPAP if they are offered a choice. The story overplays TMJ problems associated with oral appliance therapy and does not even mention the newest article that shows no damage to the TM Joint with appliance wear.

While CPAP can give dratic improvement studies have shown that the majority of patients do not use CPAP on a regular basis and even CPAP users average only 4-5 hours a night use.

The following was a letter I wrote to the author of the New York Times author:
"
I was pleased to read your article on sleep apnea. I would like to point out that the tongue is usually the site of obstruction not the soft palate. Originally ENT's thought it was the soft palate and this led to numerous failed UP3 and LAUP surgeries that had high morbidity and rarely cured apnea. Most patients still needed CPAP. The picture of the collapsed airway is also incorrect.

A major omission in your article is the fact that most patients actually use CPAP only an average 4-5 hours a night of CPAP use a night not the recommended 7-71/2 hours. Patients with untreated Sleep Apnea have a greatly increased risk of heart attacks and strokes and are in fact more likely to die in their sleep then exercising. These heart attacks and strokes usually occur in the early morning hours. Patients utilizing their CPAP for only 4-5 hours have already quit using it before they reach the time apnea causes cardiovascular events.

Thirdly you suggest dentists are prescribing the devices for treating sleep apnea. The American Academy of Sleep Medicine actually recognizes oral appliances as a first line treatment for mild to moderate sleep apnea (along with CPAP) and an alternative for severe apnea. The National Sleep Foundation stated in "SleepMatters" that "oral appliances are a therapy whose time has come." Ideally dentists are working as a team with sleep physicians to treat sleep apnea. It is not within the scope of dentistry to diagnose sleep apnea. Hopefully this will change as the NHLBI considers sleep apnea to be a TMJ disorder. (see http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf) CARDIOVASCULAR AND SLEEP RELATED CONSEQUENCES OF TEMPORO-MANDIBULAR DISORDERS.

You call CPAP the most common (true) and most effective (not true) treatment. The second part of that statement is not true if patient compliance is factored in. It would seem worth noting that CPAP is a gold standard that fails the majority of patients. Approximately 25% of patients love their CPAP from the first day and thereafter but the majority of patients abandon CPAP or use it far less time than recommended.

Ira L Shapira DDS, D,ABDSM, DAAPM, FICCMO
www.ihatecpap.com"

Labels: cpap, LAUP, New York Times, SLEEP APNEA, sleep apnea surgery, Tracheotomy, UP#

Exploding head syndrome is an interesting syndrome of unknown pathogenisis. It is documented and accepted in the International Classification of Sleep Disorders (ICSD).

An article by Casucci G, d'Onofrio F, Torelli P. discusses " trigeminal autonomic cephalalgias (TACs) and hemicrania continua, while the latter comprise classical trigeminal neuralgia, hypnic headache, primary thunderclap headache, and exploding head syndrome." This article in Neurol Sci. 2004 Oct;25 Suppl 3:S77-83 and discusses Rare primary headaches: clinical insights.


The symptoms (according to ICSD) are:

"The patient complains of a sudden loud noise or sense of explosion in the head at either the wake-sleep transition or upon waking during the night."

" The experience is not associated with significant pain complaints"

"The patient rouses immediately after the event, usually with a sense of fright"

It is considered to be a seperate entity from Idiopathic Stabbing Headache (ice pick headache) which is benign and characterized by brief stabs of pain on the side of the head.

It is also different than Thunderclap Headache which is a severe sudden-onset pain that must be considered a warning sign of a subarachnoid hemorrhage but can also be benign.

There are also cluster headaches, sleep related migraines and nocturnal paroxysmal hemicrania. It is possible that Exploding Head Syndrome is a pain free version of one of these disorders.

Severe migraines can be related to sleep apnea as well. See I HATE CPAP!! (http://www.ihatecpap.com)

PubMed abstract below:
J Neurol Neurosurg Psychiatry. 1989 Jul;52(7):907-10.
Clinical features of the exploding head syndrome.
Pearce JM.

Department of Neurology, Hull Royal Infirmary, UK.
Fifty patients suffering from the "exploding head syndrome" are described. This hitherto unreported syndrome is characterised by a sense of an explosive noise in the head usually in the twilight stage of sleep. The associated symptoms are varied, but the benign nature of the condition is emphasised and neither extensive investigation nor treatment are indicated.

PMID: 2769286 [PubMed - indexed for MEDLINE]

Neurol Sci. 2004 Oct;25 Suppl 3:S77-83.
Rare primary headaches: clinical insights.
Casucci G, d'Onofrio F, Torelli P.

U. O. di Medicina Generale, Casa di Cura San Francesco, Viale Europa 21, I-82037 Telese Terme (BN), Italy. gerardocasucci@tin.it
So-called "rare" headaches, whose prevalence rate is lower than 1% or is not known at all and have been reported in only a few dozen cases to date, constitute a very heterogeneous group. Those that are best characterised from the clinical point of view can be classified into forms with prominent autonomic features and forms with sparse or no autonomic features. Among the former are trigeminal autonomic cephalalgias (TACs) and hemicrania continua, while the latter comprise classical trigeminal neuralgia, hypnic headache, primary thunderclap headache, and exploding head syndrome. The major clinical discriminating factor for the differential diagnosis of TACs is the relationship between duration and frequency of attacks: the forms in which pain is shorter lived are those with the higher frequency of daily attacks. Other aspects to be considered are the time pattern of symptoms, intensity and timing of attacks, the patient's behaviour during the attacks, the presence of any triggering factors and of the refractory period after an induced attack, and response to therapy, especially with indomethacin. Often these are little known clinical entities, which are not easily detected in clinical practice. For some of them, e. g., thunderclap headache, it is always necessary to perform instrumental tests to exclude the presence of underlying organic diseases.

PMID: 15549575 [PubMed - indexed for MEDLINE]

Labels: nocturnal migraine, SLEEP APNEA, thunderclap headache

Thomas comments : I've been having cluster headaches for about twenty years, skipping a year every once in a while. I'm currently taking gabapentin and amitrypaline, seems to be working as of this time (we will see) and I have oxygen (havent tried it yet
) headaches wake me from sleep, last about 30 to 45 min., pacing and or burying my head in the couch cushions while trying to calm my breathing. etc.

Dr Shapira Response: I would suggest that you have a sleep study done because sleep apnea can be a exacerbate or cause cluster headaches as can bruxism and/or jaw clenching thru the trigeminal nerve. The oxygen (100%0 can often supply almost immediate relief.

Labels: cluster headaches, oxygen, SLEEP APNEA, trigeminal nerve

An abstract in SLEEP, Volume 32, Abstract Supplement, 2009 looks at periodontal disease, an extremely common and chronic inflamatory condition and its effect in animal studies on sleep. The conclusion of the authors was "Our results suggest that PD resulted in marked sleep disruption, especially in non-REM sleep, probably due to the development of orofacial pain."

This is probably a direct result of nociceptive stimulation of the trigeminal nerve causing centrl sensitization. While this was only an experimental animal study on rats it showed reductions in sleep efficiency, non-REM time and increases in arousals.

This is scary data considering the majority of americans have some level of periodontal disease (PD). PD has been implicated in heart disease, stroke, diabetes, increased infections and many other disorders. It has been assumed that this was the result of inflamatory changes in the bloodsteam and body fluids but this study could actually suggest those changes are neurological due to nociception within the trigeminal nervous system.

Labels: pain, periodontal disease, SLEEP APNEA, sleep disruption, trigeminal nerve

Patients with TMJ disorders should be evaluated for sleep disorders according to a new article in Sleep. Primary Insomnia was associated with hyperalgesia or an increased pain response. It may also be associated with central senssitazation that is found in migraines, fibromyalgia and TMD and may be a causitive factor in idiopathic pain (pain of unknown orgins)

The NHLBI (National Heart Lung and Blood Institute considers Sleep Apnea to be a TMJ disorder. The paper "Cardiovascular and Sleep Related consequences of TMJ Disorders can be found at http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf

PATIENTS WITH TMJ DISORDERS AND SLEEP PROBLEMS SHOULD BE EVALUATED BY A SLEEP PHYSICIAN! FOR MORE INFORMATION ON SLEEP APNEA, DANGERS AND TREATMENT SEE http://www.ihatecpap.com

MORNING HEADACHES ARE USUALLY THE RESULT OF TMD OR SLEEP APNEA
BRUXISM IS OFTEN A SECONDARY RESULT OF SLEEP APNEA


PubMed abstract is supplied for your convenience.
Sleep. 2009 Jun 1;32(6):779-90.
Sleep disorders and their association with laboratory pain sensitivity in temporomandibular joint disorder.

Smith MT, Wickwire EM, Grace EG, Edwards RR, Buenaver LF, Peterson S, Klick B, Haythornthwaite JA.
Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Baltimore, MD, USA. msmith62@jhmi.edu
STUDY OBJECTIVES: We characterized sleep disorder rates in temporomandibular joint disorder (TMD) and evaluated possible associations between sleep disorders and laboratory measures of pain sensitivity. DESIGN: Research diagnostic examinations were conducted, followed by two consecutive overnight polysomnographic studies with morning and evening assessments of pain threshold. SETTING: Orofacial pain clinic and inpatient sleep research facility. PARTICIPANTS: Fifty-three patients meeting research diagnostic criteria for myofascial TMD. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: We determined sleep disorder diagnostic rates and conducted algometric measures of pressure pain threshold on the masseter and forearm. Heat pain threshold was measured on the forearm; 75% met self-report criteria for sleep bruxism, but only 17% met PSG criteria for active sleep bruxism. Two or more sleep disorders were diagnosed in 43% of patients. Insomnia disorder (36%) and sleep apnea (28.4%) demonstrated the highest frequencies. Primary insomnia (PI) (26%) comprised the largest subcategory of insomnia. Even after controlling for multiple potential confounds, PI was associated with reduced mechanical and thermal pain thresholds at all sites (P < 0.05). Conversely, the respiratory disturbance index was associated with increased mechanical pain thresholds on the forearm (P < 0.05). CONCLUSIONS: High rates of PI and sleep apnea highlight the need to refer TMD patients complaining of sleep disturbance for polysomnographic evaluation. The association of PI and hyperalgesia at a nonorofacial site suggests that PI may be linked with central sensitivity and could play an etiologic role in idiopathic pain disorders. The association between sleep disordered breathing and hypoalgesia requires further study and may provide novel insight into the complex interactions between sleep and pain-regulatory processes.

Labels: BRUXISM, CENTRAL SENSITIZATION, headaches, SLEEP APNEA, TMJ DISORDERS