Sleep deprivation headache

JN Blau

CEPHALALGIA Blau JN. Sleep deprivation headache. Cephalalgia 1990;10:157-60. Oslo. ISSN 0333-1024 Headaches due to insufficient or interrupted sleep are generally labelled "tension headaches" of psychogenic origin. In 25 healthy subjects, variable amounts of sleep loss (1-3 h for 1-3 nights) caused headaches lasting from 1 h to all day. The headache was most frequently a dull ache, a heaviness or a pressure sensation felt in the forehead and/or at the vertex. Simple analgesics, purchaseable without a doctor's prescription, completely or markedly reduced the head pain in 20-60 min. Headaches due to insufficient sleep differ from tension headaches in their site, duration and response to analgesics. Assuming that pain implies a regional dysfunction, headaches caused by sleep loss provide support for the notion that sleep has a restorative function in the brain. • Headache, sleep deprivation, sleep function JN Blau, The National Hospital for Nervous Diseases, Queen Square, London WC1N 3BG, and City of London Migraine Clinic, London EC1M 6DX; Accepted 11 May 1990 Prolonged sleep is a recognized cause of headaches, but insufficient sleep is rarely mentioned in headache monographs or in the: sleep literature. Yet, in a study of 327 medical and dental students, 127 (38.8%) experienced headaches due to sleep loss (Blau, unpublished observations). The characteristics of this type of headache, not previously analysed, were therefore studied. Subjects and methods

Post-graduate doctors and medical students (n = 5) attending my teaching rounds, medical colleagues (n = 3), nurses (n = 7), hospital ancillary staff (n = 4) and acquaintances (n = 6) were asked if they experienced headache when they missed sleep. (The numbers in parentheses are those who gave a positive response.) I then asked for how long they slept normally, how many hours loss of sleep caused a headache, the reasons for missing sleep, the site and quality of pain and its duration; also which analgesics, if any, were taken, the speed and degree of response, headaches experienced at other times and whether the family practitioner had been consulted about these headaches. Results

Nineteen females and 6 males, aged 25-27 (mean 39) years, normally required 6-10 (mean 71/2) hours of sleep per day. The characteristics and variations of sleep deprivation headaches are listed in Tables 1-7. Reasons given for missing sleep were: entertainment (n = 9), reading for pleasure or studying for examinations (n = 5), working into the night-students needing to earn extra money, nurses on night shift, doctors on-call, housewives working late at home, or a teacher marking papers (n = 10), sleep Table 1. Amount of sleep loss causing headaches. 2 consecutive 2-3 consecutive Sleep loss (h) 1 night nights nights 1-3 4 0 2 2-3 4 7 2 3 or more 4 1 1

Table 2. Site of headaches. Forehead Forehead and one or both temples Forehead extending to vertex Vertex One side of forehead; behind eyes; Right or left side of head; Right or both temples; frontal or vertex or both temples Deep Superficial Uncertain

14 2 2 2 1 each

13 7 5

interrupted by children, noisy neighbours or a heat-wave (n = 4), stress or worry (n = 2), husband waking early (n = 1), watching television (n = 1), or "just going to bed late" (n = 1). The figures indicate the number of factors mentioned, some having two causes for sleep reduction. In none was alcohol consumed that could have been responsible for these headaches; 4 of the 25 had experienced "hangover headaches" (see Table 8). Only one of the 25 had mentioned this type of headache to her G.P. when consulting him about being "run-down". The others did not seek a consultation about these headaches; as one volunteer explained, "there is no point in going to a doctor about something that is your own fault". Headaches affecting the subjects in addition to those listed in Table 8 were due to travel, bright sunlight, heat, exercise, neck pain radiating to the head, and an ice-pick headache. The migraines that affected eight of the group were, on the whole, mild, having ceased in one eleven years earlier at the age of 14; two subjects had had only three Table 3. Quality of headaches. Ache Dull or heavy Pressure Throbbing Discomfort *

Three mentioned two sensations.

Table 4. Duration of headaches. 1h All morning Till mid-afternoon All day till sleep Till sleep during the day Uncertain because always took tablets *

11 8 4 3 2 Total 28*

6 7 1 10 2 2 Total 28*

Three mentioned 1 h or all day.

and five respectively in their whole life and another had one migraine attack a year; one had the visual aura alone and no ensuing headache. Discussion

Headaches due to insufficient sleep, regarded as "common", were briefly mentioned by Heyck (1) under the heading, although distinct from, vasomotor headache. The world's leading authority on sleep-head-ache relationships, James Dexter, stated in the text and listed in Table 1 of his recent review (2) that sleep deprivation can cause headache, but he did not specify which type. In the recent headache classification by a committee of the International Headache Society, sleep loss was listed as a cause of "tension.-type headache" (3) arising from stress. Black's Medical Dictionary (4) states "headache may be the only symptom of tiredness". The incidence in the previously mentioned study of more than 38% of healthy undergraduates (average age 21) citTable 5. Medication taken. Paracetamol 2 tablets 1 tablet Aspirin 2 tablets 1 tablet Ibuprofen 1-2 tablets None taken

9 2 5 4 3 4 Total 27* * Two took variable medication (aspirin or paracetamol).

Table 6. Efficacy of oral analgesics. Total relief in 20-60 min Partial relief (25-75% reduction) in 30-60 min No relief No analgesics taken

13 8 2 2

ing sleep loss as provoking some of their headaches needs independent corroboration or refutation. The response to analgesics in 20 to 60 min in 21/25 of the subjects of this report corresponds to the time of drug absorption measured by serum levels after oral medi-cation (5). This response contrasts with the failure of pain relief in tension headaches where patients frequently take analgesic tablets two to four times daily in spite of deriving no benefit. Headache is rarely mentioned in the sleep literature. However, in describing the effects of insufficient sleep for weeks or months, West (6) wrote that patients may complain of "fatigue, musculoskeletal symptoms, headache, visual disturbances, poor concentration, apathy or depression". In short-term sleep deprivation a burning sensation in the eyes was common (7) and a general lowering of the pain threshold is widely accepted (8). However, it has to be stressed that unless a symptom is sought, it may not be uncovered. For example, headache in the diabetic literature receives scant mention, let alone analysis, yet Martins and Blau (9) found three different headache types associated with insulin-induced hypoglycaemia in 50 out of 114 patients having such episodes. How does sleep deprivation cause pain in the forehead? Tiredness results in irritability Table 7. Number of additional headaches. Number of Number of other headaches subjects 0 4 1 14 2 3 3 2 4 2 Table 8. Table of additional headaches. Alcohol "hangover" headache 4 Hunger headache 4 Sleeping too long 2 Shopping headache 2 Menstrual headache 2 Tension headache 2 Sinus headache 2 Migraine visual aura only 1 classical 1 common 7 Other headaches (1 each) 6 (see text)

and impaired concentration for mental and mechanical tasks (10) and implicates the whole cerebral cortex, especially the frontal lobes. Although the brain itself is insensitive to painful stimuli, the meninges are plentifully innervated by nociceptive receptors which, above the tentorium cerebelli, derive from the first division of the trigeminal nerve, the cutaneous branches of which supply the forehead, vertex and temples. How brain disturbances induce pain in the meninges, blood vessels or more superficial structures remains unsolved. It is noteworthy that only three subjects in this series experienced a throbbing headache. What is the significance of head pain due to inadequate sleep? If pain can act as a warning (11), then prolonged sleep deprivation should have more profound effects. That is so: volunteers in physiological experiments or prisoners kept awake for a number of nights develop impaired judgment, become slow in repetitive tasks, show lack of care in dress and behaviour, become disorientated and even paranoid, deluded or hallucinated (10)-characteristic of diffuse cortical dysfunction seen in dementia. Furthermore, animals totally deprived of sleep die after several days ( for review see Karadzic) (12). A criticism voiced by colleagues is that it is surprising how both too much and too little sleep provoke pain in the head. However, a range of tolerance is biologically sound, evident in temperature variations, food intake and serum electrolytes. However, the extremes of these factors result in different responses. Hence we are led to question the

nature of a 'lie-in headache" which no one has analysed and may differ or resemble sleep deprivation headache. Research is required. Unsolicited confirmation is always gratifying. Naomi Mitchinson (13), J. S. Haldane's daughter, in her World War II diaries wrote "constant small chores to do, people to see etc, and get very very tired. Usually wake with a headache, longing to get one long night. Sleep badly but daren't take Dial in case I get a hangover". From the clinical aspect it is important not to label all sleep deprived headaches as psychogenic in origin, although some undoubtedly are. In this series the majority lost sleep in circumstances when there was no anxiety or stress, on the contrary many were having an enjoyable time. More fundamentally the function of sleep remains a frustrating mystery (14), ideas ranging from a restorative function (15) to a "behavioural survival strategem" (16). If sleep loss causes headaches as frequently as the study on undergraduates indicates, then assuming that pain indicates a regional disturbance we have a further argument supporting the notion that sleep, essential to all animals including human beings, has a restorative function (15). References

1.

Heyck H. Headache and facial pain. Differential diagnosis, pathogenesis, treatment. Stuttgart: Georg Thieme 1981:100

2.

Sahota PK, Dexter JD. Sleep and headache syndromes: A clinical review. Headache 1990;30:80-4

3.

Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988(suppl 7):33-4

4.

Black's medical dictionary. 351h ed. Ed Havard CWM. London: Black 1987:324

5.

Flower RJ, Moncada S, Vane JR. Analgesic-anti-pyretic and anti-inflammatory agents; drugs employed in the treatment of gout, In: Gilman AG, Goodman LS, Rail TW, Murad F eds Goodman and Gilman's pharmacological basis of therapeutics. New York: Macmillan 1985:674-715

6.

West LJ. Psychopathology produced by sleep deprivation. In: Kety SS, Evans EV, Williams HL eds Sleep and altered states of consciousness. Proceedings of the Association for Research in Nervous and Mental Diseases. Baltimore, Williams and Wilkins 1967;45:535-54

7.

Sassin JF. Neurological findings following short-term sleep deprivation. Arch Neurol 1970;22:54-6

8.

Kleitman N. Sleep and wakefulness. Rev. ed. Chicago: University of Chicago Press 1963:222-3

9.

Martins I, Blau JN. Headaches in insulin dependent diabetic patients. Headache 1989;29:660-3

10.

Hinckle LE Jr. The physiological state of the interrogation subject as it affects brain function. In: Biderman AD, Zimmer H eds The manipulation of brain behaviour. New York: Wiley 1961:19-50

11.

Young JZ. Philosophy and the brain. Oxford: Oxford University Press 1987:104-5

12.

Karadzic VT. Physiological changes resulting from total sleep deprivation. In: Koella WP, Levin P eds Sleep, physiology, biochemistry, psychology, clinical implications. Basic: Karger 1973:165-74

13.

Mitchinson M. Among you taking notes. The wartime diary of Naomi Mitchinson 1939-1945. Ed. by D Sheridan. Oxford: Oxford University Press 1986:250

14.

Webb WB. Sleep. In: Duncan R, Weston-Smith M eds The encyclopaedia of ignorance. Oxford: Pergamon 1977:373-6

15.

Oswald I. Sleep a restorative process: human dues. Prog Brain Res 1973;53:279-88

16.

Meddles R. On the function of sleep. Anim Behav 1975;23:676-91