Headache Treatment


Sunday, August 8, 2010

Insomnia: Sleep Therapy for Headache

Achieving restful sleep may be necessary in order to obtain a remission from frequent headaches. In may people with chronic headache, sleep deteriorates over time, resulting in days when you are half asleep, and nights when you are half awake.

How do you stop this vicious cycle? Here are some recommendations:

1) Avoid all caffeine. This is a tough one for many people! Headache sufferers who aren't achieving restful sleep at night feel that they have to "push" themselves to get through their day. Even a small habit (a single cup of coffee in the morning) may cause problems.

Here's a practical test for whether caffeine is contributing to your headaches and sleep disturbance: completely stop caffeine for three days. If you have increased fatigue, increased headache, or change in sleep patterns, it is almost certain that regular use of caffeine (even in small amounts) is contributing to your symptoms.

In some cases, due to severe headaches and fatigue when caffeine is withdrawn, it may be necessary to put a headache preventive medication in place before attempting to stop caffeine; and possible medical causes of fatigue should be thoroughly investigated.

2) Turn off all lights in the bedroom.

3) Use a sleep sound machine. Over time you will be conditioned to sleep onset when the sound is turned on. Some like the noise of a fan; the Vornado has had many compliments.

4) Do not use alcohol or any other sedatives after dinner; you may wake up as the sedative wears off.

4) Use melatonin. The proper dose and the form (sublingual, regular tablet or sustained release) may matter for effectiveness in some patients- for example, the regular (swallowed) tablet passes through the liver first, and some patients metabolize melatonin much more rapidly than others. For those who have difficulty falling asleep but no difficulty staying asleep, it is helpful to use a sublingual form (not a swallowed pill. For headache patients with difficulcty falling asleep we recommend only the one milligram size. This product is available over the web and at many vitamin shops. (Source Naturals is a brand I am familiar with). Start with one milligram under the tongue, taken in a completely dark room at the time of sleep. You may increase up to 6 tablets as needed to initiate sleep, provided you do not feel groggy the next morning. It may take two weeks to normalize sleep patterns, and headache response may take four weeks of regular sleep to be effective. Studies on melatonin effectiveness in migraine have been limited but encouraging; no significant side effects have been identified.

If vivid dreams occur (which sometimes happens after a few weeks of use) or you feel drowsy in the morning, reduce dose (as low as 1/2 tablet or less), or stop for a few days and then restart. Melatonin is useful when headaches tend to occur at certain times (end of the week "let-down" headaches, nighttime headaches, morning headaches, cluster headaches, headaches that occur seasonally).

For patients with headache who have difficulty maintaining sleep, melatonin 3 mg either at bedtime or a few hours before bedtime is recommended. If drowsiness occurs in the morning, take the dose as early as 7PM, or reduce the dose.

The combination of kava kava, an herbal relaxant medication, and melatonin at night may be very helpful. Although there have been some reports of liver function problems in patients taking very large doses (10,000 mg/day) over a long period of time, the use of up to 500 mg at night for three months or less is generally considered very safe. Kava kava has some advantages over prescription muscle relaxants in treating muscle contraction headaches and deepening sleep, allowing a helpful restorative phase for headaches during the night. We recommend kava kava 500 mg, taken at night, with melatonin, until headaches resolve. A preparation from the roots is more effective and some brands specify this source.

It may take four weeks of regular use for headaches to subside. See references at the end of this article for further information on melatonin in the treatment of headache.

5) You can add the antihistamine Benadryl (diphenhydramine), 25-50 mg at night. Side effects include dry mouth and perhaps slight urinary hesitancy. This product may be especially useful for those who have to get up at night more than once to urinate. Since histamine participates in the inflammatory cascade which is part of the headache condition, this antihistamine may be particularly effective for headache. Use only diphenhydramine- do not use combination sleep aids which contain tylenol or other substances such as decongestants, as these may worsen headache over time. There are prescription antihistamines, such as cyproheptadine, which may be used if diphenhydramine is not effective.

6) Take magnesium at night. Magnesium glycinate is a preferred form of magnesium. Both magnesium and the glycinate it is complexed to have been found in limited trials to possibly benefit migraine. Follow the directions for the size of the supplement you have purchased. In the vast majority of patients with normal renal function, the dose may be increased (often to three or more times the daily requirement of magnesium) until loose stools occur, which indicates that you are not able to absorb this dose. In patients with constipation (which also contributes to headache though many mechanisms), it may be helpful to take sufficient magnesium glycinate to induce a daily bowel movement. A less expensive but also well-absorbed form is magnesium citrate, and for many will do just as well. Avoid magnesium oxide and other more expensive forms.

7) Taper and discontinue all other nighttime sedatives and sleep medicines. Ambien, Lunesta, and other similar agents, as well as benzodiazepines (valium, etc.) all increase lighter stages of sleep, while having no effect on deeper stages of sleep which are necessary for headache recovery, and over time they lose effectiveness sometimes leaving the patient with a dependency.

8) The combination medication Limbitrol contains a small amount of librium and a small amount of amitriptyline, and is one of the most effective pharmaceutical treatments for both muscle contraction and migraine headache. The use of librium in this context (which is a relative of valium) may be necessary until a headache remission occurs. A prescription is needed for this medication. Weight gain may occur, although not all patients have this side effect (a few patients will lose weight because of the reduction in stress and cortisol with improved restful sleep). If weight gain occurs, there are slightly more complicated regimens that can be used which do not have this problem.

9) Supportive psychotherapy may help. Sometimes, an unresolved conflict or "no way out" situation will prevent sleep no matter what else is done. Previous traumatic events may also cause sleep disturbance ("PTSD"). It can be very helpful to talk things over with a professional psychologist or MSW social worker. Counseling through your religious affiliation may be available.

10) Short-duration, high intensity exercise a few times a day will help your body adapt to a normal sleep-wake cycle. Pilades exercises can be done in a few minutes twice daily in your own home, and strengthen core muscles which support a good head and neck posture. Lying on your back and doing alternating "abdominal crunches" 50 times twice daily will produce benefits for neck pain and neck-related headaches after a month of diligent exercise.

11) Sleep retraining: if all else fails, sleep retraining is almost always effective. Sleep retraining involves having a set time to get up every day of the week, and restricting the time you spend in bed to train your sleep efficiency. Decide on when you want to get up every day (you will need to do this on the weekends as well). The first night (typically a Friday night or the beginning of a period of time away from work), stay up all night. (Renting some action movies helps!) The next night, allow yourself one hour in the bed (it doesn't matter whether you sleep or not). The next night two hours, the next three and so on until you reach 6-9 hours (the amount you are comfortable with). This regimen is particularly severe, and most people do fine with less restriction (three hours in the bed the first night, four the second, etc). If this fails, start over with a more severe regimen- the choice is yours. Most people "learn to sleep better" this way. Some people gradually get "out of synch" over time;, restricting sleep one night each week may be necessary to "reset your clock".


Two articles of interest on melatonin and treatment of migraine:


The Therapeutic Potential of Melatonin in Migraines and other Headache Types
Alternative Medicine Review, August, 2001 by Joel J. Gagnier

An article on Sleep Retraining: