What Are Causes of the Most Common Sleep-Related Headache Disorders?

Migraine, Cluster, and Hypnic Headaches May Disturb Sleep

A woman wakes with a migraine headache out of sleep
A woman wakes with a migraine headache out of sleep. Getty Images

It is fairly common to have a headache after getting too little or too much sleep. In fact, headaches are frequently closely linked to sleep. What are some of the most common sleep-related headache disorders? Learn about the relationship of sleep to multiple types of head pains, including migraine, cluster, and hypnic headaches. Explore some of the causes, including what else the pain might represent, and the significant consequences.

Defining the Sleep-Related Headache Disorders

By definition, sleep-related headaches are those that occur during sleep or upon awakening from sleep. The pain may affect one side or both sides of the head and is described as being unilateral or bilateral, respectively. The headache types vary in severity and duration and often have unique associated symptoms.

It is possible to separate the headaches into different categories, factoring in their association with sleep. Most sleep-related headache conditions also occur during the daytime, including migraine, cluster, and chronic paroxysmal hemicrania headaches. In contrast, hypnic headaches occur exclusively during sleep.

There are many headaches that are not related to sleep. These include:

  • Tension headaches (often bilateral with a band-like tightness associated with muscle pain)
  • Sinus headaches (due to inflammation of the sinuses due to allergies or infection)
  • Facial headaches from infection (often tooth or ear infections)
  • Toxic headache (part of a systemic illness associated with a fever)
  • Benign intracranial hypertension (due to increased pressure within the skull)
  • Intracranial hypotension (due to decreased pressure within the skull, often after a lumbar puncture or due to a tear in the dura surrounding the brain and spinal cord)
  • Vasculitis (inflammation of the blood vessels supplying the brain)
  • Head trauma
  • Alcohol intoxication (or due to withdrawal and hangover)
  • Giant cell arteritis (older than age 50 with tenderness at the temple and associated with the risk of vision loss)

Many of these other headaches may have obvious causes or associated symptoms. In some cases, further testing may be required to determine the headache type.

What Causes Sleep-Related Headaches?

For those headaches that occur with sleep, the underlying causes are similar, but some may be associated with specific sleep disorders. There is a lot of anatomy that is important to both sleep and headaches. For example, the brainstem and hypothalamus have roles in both states. Some of the chemistry of the brain overlaps between these conditions as well, including the role of adenosine, melatonin, and orexin.

The precise triggers of headaches vary based on the underlying headache type. It is known that alcohol can provoke both cluster and chronic paroxysmal hemicrania headaches.

It is estimated that 17% of people who go to a headache clinic have nighttime or early morning headaches; half of these people had an identifiable sleep disorder.

Many headaches are benign and generally decrease in frequency with age. There may be spontaneous resolution of the headaches that lasts for months or even years. Pregnancy seems to have a variable effect, with some improving and others experiencing a worsening of their headache frequency and intensity.

The Common Sleep-Related Headache Disorders

There are four headaches that commonly occur in association with sleep. The first two listed here are described in detail elsewhere. These four sleep-related headaches include:

This headache closely resembles cluster headaches. It is characterized by severe pain that may be unilateral and localized to the eye or temple. There may be other changes affecting the face. Though the headaches are short in duration (lasting 2 to 30 minutes), they may occur more frequently, often with more than five episodes happening per day. These headaches are strongly associated with REM sleep. Fortunately, they respond well to a medication called indomethacin.

  • Hypnic headaches

This uncommon headache may cause the affected person to wake from sleep. It lasts at least 15 minutes and occurs at least 15 times per month. It usually begins at middle age or beyond (the average of onset is about 50 years old, ranging from 40 to 82 years). It is less severe compared to cluster headaches, often bilateral, and associated with nausea or aversion to light or noise. The headaches may occur one to three times per night, and many report them occurring at the same time. They are also associated with REM sleep (and rarely N3 sleep). These headaches also respond well to medications, including lithium and indomethacin, as well as to caffeine.

Considering Other Causes of Headaches in Sleep

It can be important to consult with a neurologist if you have frequent, recurrent headaches. There are other potential causes of headache that must be considered. Many headaches result from sleep disorders. Others may due to other medical or psychiatric problems. When thinking comprehensively about causes of headaches, your doctor will consider these potential contributors:

  • Bruxism (often associated with neck, back of the head, temporo-mandibular joint, or tooth pain)
  • Snoring and sleep apnea (diagnosed with a sleep study and often improved with CPAP therapy)
  • Exploding head syndrome (occurs with sleep transitions and associated with hearing an explosion in the head which is unaccompanied by pain)
  • Hypertension (increases pressure within the skull)
  • Brain tumors (increases pressure within the skull and worsened by lying down)
  • Pseudotumor cerebri (increases pressure and is associated with vision changes and obesity)
  • Arteriovenous malformations (abnormal connections of blood vessels within the brain lead to pressure abnormalities)
  • Cerebral venous thrombosis (clot in the veins serving the brain)
  • Trauma
  • Depression
  • Rebound headaches (due to overuse of pain medications, often occurring in the morning)

In reviewing such a list, the most worrisome potential cause for most people is a brain tumor. In the proper context of other symptoms and signs, further testing may be appropriate. No matter what the cause of increased pressure within the skull – ranging from tumor to blood clot – the symptoms may be similar. There may be a headache that occurs in the morning or starts soon after lying down. It improves after the affected person is up for 30 to 60 minutes. Headaches due to increased pressure may be worsened by bending, sneezing, or exertion that further increase the intracranial pressure. These conditions are associated with other neurological abnormalities and symptoms, such as nausea, vomiting, swelling in the eye, and focal deficits such as weakness or seizures.

The Consequences of Sleep Headaches and Further Evaluation

Headaches can be seriously disruptive to sleep. This may contribute to insomnia and prolong time spent lying awake at night. Depending on the headache subtype, and the underlying causes, other complications may also occur.

If you experience frequent and recurrent headaches that are disruptive to your sleep and life, start by speaking with your doctor. It may be necessary to consider evaluation by a general neurologist, headache specialist, or even by a sleep specialist. After a careful history and examination, further testing may be indicated such as neuroimaging (computed tomography or magnetic resonance imaging head scans or angiography) may be performed to rule out structural, vascular, or infectious disease processes that may cause headaches.

Sources:

American Academy of Sleep Medicine. International classification of sleep disorders, 3rd ed. Darien, IL: American Academy of Sleep Medicine, 2014

Bartleson JD, Black DF, Swanson JW. Cranial and Facial Pain. pp. 263-269. In Bradley

Brennan KC, Charles A. Sleep and headache. Semin Neurol 2009; 29:406-417.

International Headache Society Classification Subcommittee. 2004, International classification of headache disorders, 2nd ed., Cephalgia, vol. 24, suppl. 1, pp. 1-60.

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