CH and Apnea

Cephalalgia. 2007 Nov 12; [Epub ahead of print]

Refractory chronic headache associated with obstructive sleep apnoea syndrome.

Mitsikostas DD, Vikelis M, Viskos A.

Athens Naval Hospital, Neurology Department, Athens, Greece.

The aim was to investigate the comorbidity of chronic refractory headache with obstructive sleep apnoea syndrome (OSAs). Seventy-two patients (51 women and 21 men) with chronic and refractory headaches, whose headache occurred during sleep or whose sleep was accompanied by snoring, were submitted to polysomnography. Patients diagnosed with OSAs (respiratory disturbance index > 10) began continuous positive airway pressure (C-PAP) treatment and were followed up for >/= 6 months. Twenty-one cases of OSAs were identified (29.2% of the total investigated, 13.7% of the women and 66.6% of the men). Headaches were classified into several headache disorders, medication overuse headache and cluster headache being the most prevalent (nine and six of the 21 cases, respectively). In one case (1.4% of the total sample, 4.7% of all the men), the criteria for hypnic headache were fulfilled. Multivariate regression analysis revealed that age, male gender and body mass index were associated with OSAs. C-PAP treatment improved both sleep apnoea and headache in only a third of the cases. Patients suffering from chronic refractory headache associated with sleep or snoring, in particular those who are also middle-aged, overweight men, should be considered for polysomnography. C-PAP treatment alone does not seem to improve headache, but further investigation is needed.

PMID: 17999682

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Cephalalgia. 2005 Jul;25(7):488-92.

Investigation into sleep disturbance of patients suffering from cluster headache.

Nobre ME, Leal AJ, Filho PM.

Department of Neurology, Universidade Federal Fluminense, Niteroi, Brazil. menobre@rjnet.com.br

The new discoveries relating to cluster headache (CH) encouraged the study of the relationship of the hypothalamus to respiratory physiology and its comorbidity with sleep apnoea. The question is whether the apnoeas are more frequent during REM sleep and the desaturations could be involved as triggers of the cluster attacks. Furthermore, could the connection with the hypothalamus, already proved, be responsible for an alteration in the structure of REM sleep and a chemoreceptor dysfunction. We set out to analyse when polysomnography investigation is necessary in patients with CH. We studied 37 patients suffering from episodic CH, 31 (83.8%) men and six (16.2%) women. For the control group, we selected 35 individuals, 31 (88.6%) men and four (11.4%) women. There was a greater percentage of obstructive sleep apnoea (OSA) in patients with CH (58.3%) compared with the control group (14.3%) and with the general population (2-4%). In cases of pain during sleep, the majority is deflagrated during the REM phase, following a desaturation episode. A stratified analysis of the apnoea/hypnoea index relating to body mass index (BMI) and age showed that patients with CH have 8.4 times more chance of exhibiting OSA than normal individuals (P < 0001). This risk increases to 24.38 in patients with a BMI > 25 kg/m(2) and increases to 13.5 in patients > 40 years old. Surprisingly, the risk decreases sharply in patients with a BMI < 25 kg/m(2) and who are < 40 years old. Due to the fact that polysomnography is a complex, costly and sometimes difficult examination, we suggest, in concordance with the results, that it should be carried out routinely in patients with CH that exhibit a BMI of > 25 kg/m(2) and/or in patients who are > 40 years of age.

PMID: 15955035 

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Headache. 2004 Jun;44(6):607-10.

Obstructive sleep apnea and cluster headache.

Graff-Radford SB, Newman A.

The Pain Center, Cedars Sinai Medical Center and UCLA School of Dentistry, Los Angeles, CA 90048, USA.

A patient with cluster headache often wakes from sleep. The relationship to sleep apnea has been described. This study sought to confirm the relationship cluster may have with sleep apnea. METHODS: Thirty-nine consecutive patients diagnosed with episodic cluster headache according to the International Headache Society (IHS) criteria were sent for polysomnographic studies. All patients were in an active phase when they were in the study. Patients were told of the proposed relationship and were allowed to choose a sleep laboratory close to their home. RESULTS: Thirty-one patients with episodic cluster headache completed an overnight polysomnographic study. Twenty-three were male and eight female. The average age was 51 years (range 33 to 78 years). The average weight was 173 pounds (range 117 to 260 pounds). A total of 80.64% had sleep apnea (25/31). Average respiratory depression index (RDI) was 19.0 (SD 14.6) with 6 patients having no apnea, 10 having mild, 11 having moderate, and 4 having severe apnea (RDI < 5 = none; RDI 5 to 20 mild; RDI 20 to 40 moderate; RDI > 40 severe). Oxygen saturation decreased on average to 88.4% SD 4.5. Sleep efficiency was 76.2% (SD 13.4). CONCLUSIONS: The data closely approximate those of Chervin et al, where 80% had RDI > 5. The relationship sleep apnea has in the perpetuation or precipitation of cluster headache is still to be determined. There are some reports that treatment stops the cluster but there is no prospective study. The high incidence (80.64%) seen in this population suggests the cluster patient should receive a sleep evaluation and perhaps intervention with continuous positive airway pressure (CPAP) or an appropriate dental device.

PMID: 15186306

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Cephalalgia. 2003 May;23(4):276-9.

Cluster headache associated with sleep apnoea.

Nobre ME, Filho PF, Dominici M.

Universidade Federal Fluminense, Rio de Janeiro, Brasil. eduarda@imagelink.com.br

This study of sleep changes in patients with cluster headache (CH) was conducted in view of the nocturnal predominance of this condition, the efficacy of oxygen and the fact that the attacks follow oxygen desaturation. Proposed mechanisms include impairment of carotid body activity secondary to hypothalamic vasomotor regulatory dysfunction. Sixteen patients with episodic CH and 29 healthy volunteers underwent nocturnal polysomnography. Five (31.3%) patients with episodic CH were found to have sleep apnoea (SA). Two patients with SA experienced two attacks during the study period. The attacks followed episodes of oxygen desaturation and were associated with REM sleep. In two patients with SA and CH, treatment with continuous positive airway pressure abolished their oxygen desaturation, sleep apnoeas and headaches. Our study confirmed the high percentage of CH associated with SA. We suggest that oxygen desaturation may be a trigger factor in some patients and play a role in the pathogenesis of CH.

PMID: 12716345 

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Sleep Res Online. 2000;3(3):107-12.

Timing patterns of cluster headaches and association with symptoms of obstructive sleep apnea.

Chervin RD, Zallek SN, Lin X, Hall JM, Sharma N, Hedger KM.

Sleep Disorders Center, Department of Neurology, University of Michigan, Ann Harbor, Michigan, USA. chervin@umich.edu

Cluster headaches (CH) frequently recur at the same point in the circadian cycle, often during sleep. They may, in some cases, represent a susceptible individual's response to hypoxemia or other physiological changes induced by obstructive sleep apnea (OSA). If and when this mechanism exists, timing of CH close to the onset of sleep-and therefore OSA-might be expected. We questioned 36 subjects with CH about the times at which their CH usually occurred and about several symptoms known to be predictive of OSA, including habitual snoring, loud snoring, observed apneas and excessive daytime sleepiness. We then used logistic regression to determine whether occurrence of CH in each of six time periods was associated with OSA symptoms. The 23 subjects (64%) who reported CH in the first half of a typical night's sleep also tended to report headaches during the midday/afternoon period. Symptoms of OSA, and in particular habitual snoring, were predictive of both first-half-of-the-night and midday/afternoon CH (p<.05). Thirty-one subjects (86%) reported that their CH were sleep-related, usually occurring during any part of the night or on awakening, but symptoms of OSA were not predictive of this timing pattern. In short, several OSA symptoms showed an association with CH occurrence in the first half of the night but not with sleep-related CH in general. These findings suggest that in some patients, physiological consequences of OSA may trigger CH during the first few hours of sleep and thereby influence the timing of subsequent daytime headaches.

PMID: 11382908 

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Sleep disordered breathing in patients with cluster headache.

Chervin RD, Zallek SN, Lin X, Hall JM, Sharma N, Hedger KM.

Sleep Disorders Center, Department of Neurology, University of Michigan, Ann Arbor 48109-0117, USA. chervin@umich.edu

OBJECTIVE: To study subjects with active or inactive cluster headache (CH) for occult sleep disordered breathing (SDB). BACKGROUND: CH frequently occurs during sleep. The authors previously found that symptoms of SDB predicted reported occurrence of CH in the first half of the night, which suggested that CH could be triggered in some cases by unrecognized SDB. METHODS: The authors performed polysomnography in 25 adults (22 men) with CH. Subjects were not selected for any sleep-related complaint. In addition to standard measures, studies included monitoring of end-tidal carbon dioxide (n = 22), and esophageal pressure (n = 20). RESULTS: The rate of apneas and hypopneas per hour of sleep was >5 in 20 subjects (80%; 95% CI, 64% to 96%), minimum oxygen saturation was <90% in 10 subjects, maximum negative esophageal pressure ranged from -13 to -65 cm H2O, and maximum end-tidal carbon dioxide was > or =50 mm Hg in eight subjects. The eight subjects with active (versus inactive) CH at the time of study had higher maximum end-tidal carbon dioxide levels (50 +/- 3 versus 44 +/- 5 mm Hg; p = 0.0007). More severe oxygen desaturation was associated with reports that CH typically occurred in the first half of the nocturnal sleep period (p = 0.008). CONCLUSIONS: SDB occurred in the majority of patients with CH. Evaluation of a patient with CH should include consideration that SDB may be present.

PMID: 10881257 

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Improvement in cluster headache after treatment for obstructive sleep apnea.

Nath Zallek S, Chervin RD.

Sleep Disorders Center, Department of Neurology, University of Michigan, Ann Arbor, MI, USA

A 60-year-old man with cluster headaches (CH), refractory to many different medications for 9 years, was found to have obstructive sleep apnea (OSA). Treatment with nasal continuous positive airway pressure (CPAP) was associated with substantial reductions in the frequency and severity of cluster headaches. These observations suggest that obstructive sleep apnea may trigger CH during susceptible periods.

PMID: 10767655 

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Headache. 1995 Nov-Dec;35(10):590-6.

The relationship between headaches and sleep disturbances.

Paiva T, Batista A, Martins P, Martins A.

EEG and Sleep Laboratory, Centro de Estudos Egas Moniz, Neurology, Hospital Santa Maria, Lisboa, Portugal.

The relationship between headaches and sleep disturbances is complex and difficult to analyze. Both symptoms may have causal relations, or may be associated in the same patient with mutual reinforcements. We studied 25 patients presenting with morning or nocturnal headaches. Standard headache diagnosis and polysomnography were performed. After polysomnography, the diagnoses were reevaluated. The main headache entities were cluster, chronic paroxysmal hemicrania, migraine, tension, combined headache, and chronic substance abuse headache. For each group, headache, sleep data, and changes in diagnosis are discussed. The diagnosis was changed in 13 patients; the final diagnoses were periodic movements of sleep, fibromyalgia syndrome, and obstructive sleep apnea. The diagnoses of cluster headache and chronic paroxysmal hemicrania were not modified by polysomnography. The migraine and tension headache groups had a relative male preponderance, and the diagnosis was changed in approximately half of the patients. This was also observed in combined headaches. Patients who had chronic substance abuse headaches had mainly insomnia, which in some cases, was relieved by stopping medication. Data were also analyzed in terms of simple models linking headache and sleep disturbances. Such an approach allowed the identification of several modes of mutual interaction. In summary, morning or nocturnal headaches are frequent indicators of a sleep disturbance and their presence might justify polysomnography, and the use of simple clinical models may be useful for understanding the complex relationship between headache and sleep.

PMID: 8550359 

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Sleep. 1993 Aug;16(5):487-9.

Nocturnal cluster headache associated with sleep apnea. A case report.

Buckle P, Kerr P, Kryger M.

Section of Respiratory Diseases, University of Manitoba, Winnipeg, Canada.

We describe a 49-year-old man with chronic cluster headache unresponsive to all medications. Following investigation in the sleep lab he was found to have obstructive sleep apnea (OSA) with associated oxygen desaturations during rapid eye movement (REM) sleep. He awakened during one of these episodes with a typical headache. Treatment with nasal CPAP abolished his OSA and desaturations, and largely abolished his headaches. He then developed central apneas during REM sleep. Further treatment with BiPAP, with a set backup rate, abolished both the apneas and the headaches. We conclude that there may be a link between nocturnal cluster headaches and sleep apnea.

PMID: 8378690 

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Cephalalgia. 1984 Mar;4(1):33-8.

Sleep apnea in cluster headache.

Kudrow L, McGinty DJ, Phillips ER, Stevenson M.

The impetus to study sleep changes in a cluster population arose from a recent hypothesis that predicted the finding of sleep apnea in this disorder. It holds that cluster attacks may occur in response to oxygen desaturation. Proposed mechanisms involve impairment of carotid body activity secondary to hypothalamic-vasomotor regulatory dysfunction. Five chronic and five episodic cluster patients underwent nocturnal polysomnography, utilizing standard equipment for monitoring sleep status, cardiac activity, nasal and buccal air flow change, chest and abdominal breathing, muscle activity and oxygen saturation. All episodic patients and one of five chronic patients were found to have sleep apnea (60%). Mean apneas per hour during NREM sleep were similar to that of REM sleep; 26.7 and 28.2, respectively. Six patients with sleep apnea experienced 14 cluster headache attacks during the study period. Eight attacks (57%) followed episodes of oxygen desaturation ranging from 65% to 85%. In the sleep apnea group, 8 out of 14 attacks (57%) were associated with REM; three without, and five following oxygen desaturation. Of the non-apnea group, all of whom had chronic cluster headache, none of 5 attacks were associated with oxygen desaturation, and only 2/5 attacks occurred in relation to REM. Thus, our study showed that sleep apnea was a common finding in a randomly selected group of episodic cluster patients; and most nocturnal attacks were preceded by oxyhemoglobin desaturation and REM-related. These findings were uncommon in the chronic cluster group.

PMID: 6713522

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Page Last Updated:  11/18/2007

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