Patients with migraine are categorized as having either episodic migraine (EM), in which they have fewer than 15 headache days per month, or chronic migraine (CM), in which they have 15 or more headache days per month for more than 3 months, with migraine features presenting 8 or more days per month. “Both EM and CM are associated with a range of medical, neurologic, and psychiatric comorbidities that may exacerbate the disease, complicate treatment, and reduce health-related quality of life,” says Dawn C. Buse, PhD. “These comorbidities include sleep disorders, such as sleep apnea, insomnia, circadian rhythm (ie, sleep-wake) disorders, and sleep movement disorders.”

According to Dr. Buse, sleep is essential in the regulation of a wide range of homeostatic functions, and dysregulation of sleep processes may trigger migraine attacks while also being a risk factor for the new onset of chronic migraine. Sleep apnea and abnormal sleeping patterns have been linked to migraine onset, severity, and progression in previous research, but studies are needed to better understand the connection. Clinicians still lack a full understanding of the impact of sleep disorders as comorbidities of migraine.

For a study published in Headache, Dr. Buse and colleagues sought to better elucidate the association of sleep apnea and sleep quality with EM and CM. They conducted a cross-sectional analysis of data from the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study. “CaMEO is a longitudinal study that used a series of web-based surveys over 15 months to assess migraine symptoms, burden, and patterns of healthcare utilization among participants,” explains Dr. Buse. “We included validated questionnaires to assess many comorbidities.” The study included sleep assessments for 12,810 people with migraine. Participants were stratified by EM (n=11,699) and CM (n=1,111) migraine and by BMI.

Examining Key Findings

According to Dr. Buse, sleep apnea and poor sleep quality were more common among people with migraine than the general population. “Similar to what is reported in analyses in the general population, rates of sleep apnea and poor sleep quality increased with older age and higher BMI as well as among men,” she says. Participants with CM were more likely to be categorized as high risk for sleep apnea than those with EM (Table). Overall, 37.0% of participants who completed the Berlin Questionnaire for Sleep Apnea were deemed “high risk” for sleep apnea. The Berlin Questionnaire estimates the risk of sleep apnea by assessing snoring behavior, wake time sleepiness or fatigue, and patients’ history of obesity or hypertension. “In addition, our study examined other important sleep indices using the Medical Outcomes Study (MOS) Sleep Scale survey instrument,” Dr. Buse says. “Using the MOS instrument, we found that people with CM were more likely to have poor sleep quality than those with EM on a range of indices, including sleep disturbances, snoring, shortness of breath during sleep, daytime somnolence, and lack of getting enough sleep to feel well rested.” Women reported higher rates of sleep disturbance than men but reports of these problems were high across both genders.

Proactive Efforts Needed

Studies have established that there is a relationship between migraine and poor sleep, but more research is necessary to explore mechanisms to improve adherence to treatments for sleep apnea and the benefits of such therapies in people with CM and EM, according to Dr. Buse. She notes that the study findings suggest assessing sleep quality and screening for sleep apnea are valuable approaches when managing people with migraine, especially those with CM, but also in men, older patients, and those with higher BMIs.

“All people with migraine, particularly those with sleep disturbances, could benefit from being educated about behavioral sleep regulation and healthy sleep hygiene,” says Dr. Buse. “Patients with migraine who screen positive for sleep apnea should be referred for additional evaluation and possible treatment with continuous positive airway pressure (CPAP), when appropriate. These efforts should include supportive education to ensure adequate adherence to CPAP treatment. Cognitive behavioral therapy should be considered for patients with insomnia.”