Cluster Headache and Sleep

Neurologist and Sleep Medicine specialist Dr. James R. Weintraub provides answers to frequently asked questions regarding the relationship between cluster headache and sleep.

Is there a relationship between sleep disorders and cluster headaches?

Possibly. Cluster headaches often occur in the evening or within several hours of falling asleep. They can be severe and intense enough to awaken the patient from sleep. We believe the transition from REM sleep (the dreaming state of sleep) to non-REM sleep may play a role in triggering these attacks.

Of course, headaches and sleep difficulties are common complaints of our patients. The relationship between sleep disorders and headache is complicated, poorly defined, and the subject of ongoing scientific investigation. Other factors may play a role in triggering cluster headaches, such as environmental changes, circadian rhythm, and changes in physical, emotional, or intellectual activity.

What are the stages of sleep and how do they relate to the development of cluster headaches?

Stage I sleep is the initial stage that is very "light" and nonrestorative (not refreshing). Stage II sleep is a prolonged, deeper stage; the stage in which we spend most of the night. Stage III/IV is delta slow wave sleep; it is a deep, restorative state that we need in order to feel awake and alert the following day.

REM (rapid eye movement) sleep is the dreaming state which we enter 4?6 times per night. The transition from REM sleep to one of the other stages of sleep may result in certain changes in brain activity which may precipitate cluster headache attacks.

What treatment options are available for cluster headaches triggered by sleep disorders?

Changes in the sleep/wake schedule are known to have a significant effect on cluster headaches. Physicians often facilitate sleep deprivation for a patient to help prevent the onset of a cluster headache the following day and for subsequent days. Melatonin may also be effective in the prevention of cluster headache attacks at night, with some patients finding it to be effective for chronic cluster headache. The optimal dose may be 9 mg taken at bedtime.

What tests are performed to determine if a sleep disorder is contributing to the development of cluster headaches?

A nighttime sleep study can be performed to determine if a patient is experiencing periods of apnea (episodes in which breathing is interrupted). Apnea that occurs during the night results in disrupted sleep and significant daytime sleepiness the following day. Obstructive sleep apnea is characterized by loud snoring. This condition is more common in men, and middle-aged and overweight individuals. Treatment for obstructive sleep apnea includes nasal CPAP (continuous positive airway pressure) and weight loss.

What is narcolepsy, and does it play a role in cluster headache attacks?

Narcolepsy is a sleep disorder characterized by sudden sleep attacks, sleep paralysis, vivid hallucinations, and sudden loss of muscle tone (cataplexy). These symptoms occur during the day. While narcolepsy is a REM sleep disorder, it does not appear to be a trigger for cluster headache attacks.

Other comments

Further studies are needed to assess how patients with cluster headaches will respond to various treatments. Patients who suffer from both problems (cluster headaches and sleep problems) often need aggressive treatment for both conditions.