VIII. HEADACHES RELATED TO SLEEP.
Many causes are
possible-- some serious, but others not. Most
sleep-related headaches are not due to brain tumors or other serious
brain abnormalities. Causes include:
apnea -- an extremely common cause of headaches on awakening. May
involve dull, pressure like pain or a pounding headache. May result
in part from repeated swings in cerebrospinal fluid pressure: induced
by struggling to overcome upper airway collapse (which can cause a headache
similar to that experienced following a ‘spinal tap’). Look
for sleep apnea symptoms as listed above in the section on night sweats. Also,
note if they are more intense when you find that you were sleeping on
your back, and also, if they are milder or less frequent when you sleep
in a reclining chair.
-Migraine -- also a common cause of headaches on awakening, especially after ‘sleeping
in late’ (for example, on weekends). These are usually “sick
headaches” with nausea (and in some cases, with vomiting, sweating,
sensitivity to bright lights, and even diarrhea).
may begin on one side of the head with subsequent spread to both sides. The
pain tends to be pounding or throbbing, and it usually will be partly
relieved by pressing over the scalp, or by applying cold compresses --
at least when the headache is just beginning.
symptoms (sparkling lights, shimmering, bright spots or patterns, or
blurring) or other neurological symptoms can occur.Usual
reaction to pain: person wants to lie in a darkened room. Precipitating
factors include stress, relief from stress, many specific foods, alcohol,
menstrual periods, travel, changes in weather.
congestion -- usually occurs over the sinuses, with a pressure
sensation and sometimes with other symptoms of nasal congestion. Relieved
by achieving sinus drainage (for example, with hot showers, warm compresses,
saline sprays or decongestants).
pain related to arthritis and other orthopedic problems may
be aggravated by sleep-- sometimes related to specific pillows and
headaches are intense, excruciating headaches, involving one
side of the face with watering and often redness of the eye, drooping
of the eyelid and nasal congestion on the same side as the pain.
last 30-90 minutes and occur 1-6 times per day, in clusters lasting
weeks to months.
occur in sleep and specifically, in conjunction with REM sleep.
reaction to pain: frantic pacing, agitation, hitting the wall, etc.
common in men over age 20 with a smoking history.
ingestion and sleep apnea can precipitate cluster attacks, and inhalation
of oxygen may relieve them.
paroxysmal hemicrania is a disorder that somewhat resembles cluster headache
in the following respects: similar location and symptoms (eye watering,
nasal congestion, etc.) and occurrence from REM sleep. However,
it differs in the following:
are less prolonged (5-30 minutes) and more frequent (ten to thirty attacks
primarily in women, sometimes at younger ages, and in some patients can
be precipitated by head turning.
other medical, neurological and sleep disorders can cause sleep-related
headaches. If your headaches don’t seem to fall within any
of the types just described, ask yourself the following questions and
discuss them with your doctor:
wake me up -- or do I notice them when I awaken?
do they occur? Middle of the night or on final
awakening? From REM or non-REM sleep? Weekends or weekdays?
--Where are they located? One or both sides of head, forehead,
eyes, face, jaws/ TM joints, top/ back of head or neck?
--How do they feel? Pounding, throbbing? Dull steady
pressure, or squeezing like a vise? Sharp, jabbing pain?
--What other symptoms occur at the same time as my headaches? Nausea,
visual symptoms, etc.
--What makes them worse? Sleeping in late, sleeping on my
back, sleeping without or with pillows, stress or relief from stress, nasal
congestion, alcohol, certain foods?
-What makes them better? Pressing over my scalp, caffeine,
prescribed or over-the-counter medications, eating, relieving sinus congestion,
IX. ENURESIS (BED WETTING)
AND FREQUENT URINATION AT NIGHT (NOCTURIA).
to persistent bedwetting beyond age 5: without long “dry periods” followed
by relapses. Often “runs
in families”, perhaps due to an inherited tendency for delayed
maturation of bladder control. Sometimes, it appears that affected
relatives outgrow the problem at roughly the same age!
associated with a tendency to sleep very soundly and to have other abnormal
sleep-related behaviors and events.
respond to fluid restriction, exercises to increase bladder capacity
and rewards for dry nights. While special nasal sprays (which contain
a hormone that reduces urine output) and oral medications may help, it
is safest if the problem can be managed without any risk of drug side
to development of bedwetting in older children and adults who had been
free of this problem.
more likely than primary enuresis to be caused by an underlying medical
problem: including (but not limited to) sleep
apnea, diabetes, urinary
infections, kidney/bladder problems, and seizures.
urinalysis and urine culture should always be considered, as well as checking
for indications of sleep apnea (which, in addition to snoring, morning
headaches, sleepiness and other symptoms as listed above under Night Sweats,
can cause distractible, hyperactive behavior in children). Excessive
thirst and increased daytime urination should prompt suspicions of diabetes. Referral
to a urologist is particularly appropriate when waking loss of urine, abnormalities
of the urinary stream and repeated urinary infections have been experienced.
(frequent awakenings to urinate).
problems (ex: prostate enlargement in men and bladder dysfunction
in women) can be responsible, sleep apnea is an extremely common
cause of this symptom. One study found that nearly half of patients
seeing urologists for nocturia had sleep apnea as the underlying
in the pressure within the chest induce increased release of a
hormone from the heart called atrial natiuretic peptide, which
causes increased sodium in the urine--which in turn pulls more
water from the bloodstream into the urine, and urine volumes hence
are increased. It is not surprising, then, that many patients with
sleep apnea are amazed by the fact that once their sleep apnea
is treated, they no longer awaken repeatedly to urinate.
ABNORMAL HEART RHYTHMS DURING SLEEP.
The brain modulates
our heart rhythm in ways that change dramatically during sleep. For
example, some people experience excessive slowing of their heart, even
to the point their heart stops beating completely (asystoles) for periods
of 8-10 seconds or longer, in REM sleep, during bursts of rapid eye movements
and as a consequence of abrupt brain activity that influences heart rate. Such
can happen even if they have no heart disease per se. Also,
some abnormal sleep events (particularly sleep
apnea) also can alter heart
rhythm. For example, some patients show excessive slowing of their
heart -- even to the point of asystoles (complete lack of any heartbeat)
while they are struggling to overcome upper airway collapse -- after which
their heart may race, and at which point flurries of abnormal beats or “extra
Some patients arouse
when having abnormal rhythms and may experience palpitations, light-headedness,
shortness of breath or chest discomfort. However, many
never awaken at these times, and their problem may only be detected during
24-hr. ambulatory (“Holter”) heart monitoring or during hospitalizations.
Finally, it is important to know that one particular and very common heart
rhythm abnormality (atrial fibrillation) is strongly associated with sleep
apnea and can make it more severe.
Sleep evaluations can
help determine whether treatment of underlying sleep problems will take
care of these sometimes serious rhythm abnormalities, or if instead, specific
heart medications or pacemakers will be necessary
here to continue...