Sleep and Health... Connecting the Dots
This series originates from a Grand Rounds presentation to Neurology and Neurosurgery residents and staff at the University of Kansas Medical Center. Adjunct professer, Vernon Rowe, MD presented his research and experiences as a neurologist and sleep medicine physician, to impress upon those in attendance, the underappreciated connection that sleep disorders have on many common neurological and neurosurgical diseases.
Headache and the Link to Sleep Disorders.
According to the National Headache Foundation, nearly 13% of the U.S. population suffers from headaches that classify as migraine, with over half of those resulting in loss of productivity at work or school. Facts and figures of the impact that headache has on society are certainly not news to a group of neurology residents and physicians. What is newsworthy, however, to this group is new information about the role that sleep and sleep quality play in headache.
The data presented were derived from Rowe’s practice at the MidAmerica Neuroscience Institute. This institute is composed of four clinical centers of excellence and a research foundation. One of the centers of excellence is a nationally accredited sleep disorders center.
The merger of electronic medical records with the digitized sleep center database, captured during sleep studies (polysomnography) confirmed many of the "hunches" about the linkage of sleep disorders and headache.
Patients with sleep disorders and headache have many traits in common:
• Age 25-40
• Headaches that interfere with daily activities
• Excessive daytime sleepiness and snoring
• Near normal BMI
The first four characteristics make one think of obstructive sleep apnea (OSA) but the fifth characteristic doesn’t fit the mold of classica OSA.
“We can all spot OSA from across the room when we see the 300 pound man with a 19 inch neck. We know he needs an evaluation for sleep apnea. What we’ve discovered in our research is that sleep disordered breathing (SDB) of a milder form can lead to headache.”
These younger patients that don’t have full-blown OSA, but are struggling with milder forms of SDB, like Upper Airway Resistance Syndrome (UARS), resort to sleep on their side or belly to breathe. These patients are paying a price for sleeping in a less than optimal anatomical position. During polysomnography, we noticed that these folks don’t achieve REM sleep while sleeping on their back. Unaware, they switch to side or belly sleep positions when their airway becomes restricted. Now with the airway open, they cycle through the necessary stages of sleep, including REM.
Solving the Breathing Problem Creates a New Problem
During REM sleep, our voluntary muscles relax and are essentially paralyzed to prevent us from acting out our dreams. Side sleeping creates abnormal alignment of the cervical spine which isn’t structurally supported during REM sleep.
The progression of sleep disorder to headache looks like this:
1. Sleep disordered breathing yields side sleeping.
2. Side sleeping during REM sleep results in neck and shoulder problems.
3. Night after night of side sleeping manifests in cervical radiculopathy.
4. Cervical radiculopathy presents as severe neck pain and/or triggers migraine in those predisposed to headache.
The bad news is that this is a very common problem in our society. The good news is that this is a very fixable problem. The problem can be fixed way back at step number 1 above. By correctly identifying the sleep disorder and treating it with something as simple as CPAP or an oral appliance, the cervical radiculopathy and headache don’t have to manifest.
The Solution: Day Fix / Night Fix
Many of the patients we see at our Headache Center work with our physical therapists who have become experts in correcting and strengthening the muscles of the shoulders, upper back and neck. Through a short regimen of physical therapy (DAY) and CPAP therapy (NIGHT), many of these patients find relief of their migraine symptoms and reduce their pharmaceutical reliance to a minimum, if not zero. Simple solutions to complex problems can occur by treating patients in a comprehensive outpatient setting and studying the data.
This research was presented at both American Academy of Neurology (AAN) and the SLEEP 2011 (Associated Professional Sleep Societies). You can download a PDF of the research presentation.