Insomnia and circadian variation of attacks in episodic migraine

OBJECTIVES: To assess the influence of insomnia on the 24-hour temporal pattern of migraine. BACKGROUND: Migraine attacks have been reported to occur in a harmonic (monophasic) or a biphasic 24-hour cyclic manner, and in some studies to have preponderance in the morning hours. The influence of insomnia on the circadian pattern has not been evaluated. METHOD: Based on a previous study of the circadian variation in migraine, an explorative data analysis was made to compare the circadian pattern of insomnia-related migraine attacks to the circadian pattern of migraine attacks not related to insomnia. If the patients reported difficulties in falling asleep and/or maintaining sleep the night prior to the reported attack or the night the attack occurred, the attack was defined as insomnia-related. Relapses were not counted as distinctive attacks. RESULTS: Sixty-eight female migraineurs (mean +/- SD age: 35.5 +/- 7.0) prospectively recorded 1869 migraine attacks. Five hundred-and-thirty-three attacks (29%) were insomnia-related. Insomnia-related attacks had a biphasic temporal pattern with one peak in the morning hours and one peak after noon. They had a preponderance in the morning hours compared to attacks not related to insomnia (t= 3.27, df = 62, P= .002). In 79% of attacks insomnia was experienced prior to the headache. CONCLUSIONS: Episodic morning migraine is associated with insomnia. The cause and consequences of insomnia in migraine is not clarified, but sleep obviously protects against attacks rather than provokes them.     

Sleep and migraine: an actigraphic study

The aim of the study was to evaluate sleep of children with migraine during the interictal period and the modifications of sleep which precede, are concomitant with, or follow migraine attacks. Eighteen patients with migraine without aura were compared with a group of 17 healthy age-matched children. Sleep parameters were monitored for two full weeks by means of actigraphs and self-report diaries. Headache diaries were also filled out in order to evaluate the occurrence and the characteristics of migraine attacks. Fifty-seven attacks were recorded during the monitoring period. During the interictal period, sleep parameters of children suffering from migraine did not differ from those of controls; only sleep onset latency was slightly prolonged in the migraine group. Timing of the attack affected nocturnal motor activity which presented the lowest values on the night preceding the attack, indicating a decrease in cortical activation during sleep preceding migraine attacks. Further studies should clarify if the observed reduction in nocturnal motor activity close to the attack is related to neurotransmitter imbalance.     

Seasonal variation in migraine

Our group has previously shown that migraineurs, as opposed to individuals with other headaches, are more likely to have headache during the bright arctic summer than during the polar night season. We set out to investigate the impact of seasonal light exposure in migraine with and without aura. We performed a questionnaire-based study of 169 female volunteer migraineurs in an arctic area where light conditions during summer and winter seasons are extreme. We included 98 patients with migraine with aura (MA) and 71 with migraine without aura (MoA). One hundred and seven patients (63%) reported seasonal variation in migraine attack frequency. Close to half (47%) of patients with aura, but only 17% of patients without aura, reported more frequent attacks during the light season (P < 0.001). Patients with MA reported interictal light hypersensitivity and light exposure as an attack precipitating factor significantly more often than individuals with MoA. They also reported significantly more frequent use of sunglasses to prevent attacks. We found no significant differences between MA and MoA as regards sleep disturbances, use of oral contraceptives, impact of headache or circadian variations. Seasonal periodicity of migraine in an arctic population with more frequent attacks during the light season is a convincing phenomenon in MA but not in MoA. The amount of light exposure seems to be pivotal to this variation.     

The Impact of Shift Work on Brazilian Train Drivers with Different Chronotypes: A Comparative Analysis through Objective and Subjective Criteria

Objective

The aim of this study was to compare sleep pattern, tiredness sensation and quality of life between different chronotypes in train drivers from a Brazilian transportation company.

Subjects and Methods

Ninety-one train drivers, working a rotary work schedule including night shift, were divided into three groups according to their chronotype (morning types, intermediate or evening types) and were assessed for their sleep and quality of life, as characterized by a subjective questionnaire and the Psychomotor Vigilance Task (PVT), applied before and immediately after the night shift. The pattern of activity and rest was measured for 10 days by actigraphy, and the chronotype was determined through the Morningness-Eveningness Questionnaire.

Results

Forty-one (45.1s%) individuals were classified as morning type, 44 (48.4s%) were classified as intermediate and 6 (6.6s%) as evening type. The evening types had a tendency to remain awake for a longer period of time before the night shift (p = 0.05) and scored worse overall for quality of life compared to morning types (p = 0.11). There was no significant difference between the groups regarding variability in the PVT performance, even when covaried by the period of waking time before the test. There was no significant difference either in feelings of fatigue before and after starting the shift.

Conclusion

Although the evening type number was small, evening type individuals scored worse relative to sleep and quality of life than morning type individuals.Key Words: Chronotype, Fatigue, Shift work, Psychomotor Vigilance Task, Actigraphy     

Self-assessed quality of sleep, occupational health, working environment, illness experience and job satisfaction of female nurses working different combination of shifts

AIM: The aim of this study was to describe and compare the self-assessed quality of sleep, occupational health, working environment, illness experience and job satisfaction among female nurses working different combinations of shifts. BACKGROUND: Evidence from several studies indicates that there is an association between the disruption of the circadian cycle caused by shift work and adverse health effects. METHODS: A cross-sectional design was used with a sample of 348 nurses drawn from the registry of the Icelandic Nurses' Association, representing 17% of the workforce of Icelandic nurses. A self-administered questionnaire, measuring occupational health, quality of sleep, the illness experience, job satisfaction and working environment was used. Data were analysed according to type of shift (days only, rotating days/evenings, rotating days/evenings/nights) by use of analysis of variance and chi-square. RESULTS: No difference was found between participants based on type of shift with regard to the illness experience, job satisfaction and quality of sleep. Nurses working rotating day/evening/night shifts reported a longer working day, more stressful environmental risk factors, more strenuous work and that they were less able to control their work-pace. In general, the nurses reported low severity of symptoms; however, nurses working rotating days/evenings shifts experienced more severe gastrointestinal and musculoskeletal symptoms when compared with others. This was explained by the short rest period provided for between evening and morning shifts. CONCLUSIONS: In general Icelandic nurses are satisfied with their work and their shift assignment does not seem to pathologically disrupt their circadian cycle. Nevertheless, nursing directors are advised to look more closely at the organization of nurses' work during night shifts, as well as the rest period for nurses changing from evening to day shifts.     

Migraine Chronobiology

This study was undertaken to determine whether migraine attacks exhibit circadian, menstrual, or seasonal variations in frequency and, thus, to characterize more precisely this relapsing, remittent pleomorphic disease. An analysis of 3582 well-documented migraine attacks in 1698 adults was undertaken. The demographics of the study population accurately represented the known epidemiology of the disease. Migraine attacks started more frequently between 4 am and 9 am and within the first few days after onset of menses; this migraine periodicity is strongest amongst women not using oral contraceptives. Seasonal periodicity, if any, is clearly weaker than circadian or menstrual. These chronobiological features may assist in the differential diagnosis of migraine from premenstrual headache and fibromyalgia.     

Salivary cortisol, dehydroepiandrosteronesulphate (DHEA–S) and testosterone in women with chronic migraine

Hypothalamus–pituitaryadrenal (HPA) axis activity was monitored in 20 women with chronic migraine (CM), previously affected by medication overuse headache (MOH), in comparison to healthy women (20 subjects) by measuring salivary cortisol, testosterone, dehydroepiandrosterone–sulphate (DHEA–S) levels, and their ratios, one week after the end of the MOH rehabilitation procedure. The participants were instructed how to collect saliva samples at home, a procedure that was performed twice a day (08:00 a.m. and 8:00 p.m.). Morning and evening levels of cortisol were significantly increased in CM patients with respect to controls. With regard to the cortisol/DHEA–S ratio, an inverse marker of psycho–physical wellbeing, CM women showed significantly higher values than controls. Moreover, testosterone/cortisol ratios (anabolic/catabolic index of physical performance) were significantly lower in CM patients than in controls. In the present study, CM appears not to be associated with an impairment of cortisol and DHEAS circadian fluctuation; however, CM patients present alterations in HPA axis function that might contribute to metabolic and psychological alterations that have also been associated with CM.     

Low urinary 6-sulphatoxymelatonin concentrations in acute migraine

Substantial evidence points to melatonin as playing a role in the regulation of circadian rhythms, sleep, and headache disorders. The objective of the study was to assess 6-sulphatoxymelatonin (aMT6s) levels in a large consecutive series of patients with migraine, comparing with controls. A total of 220 subjects were evaluated-146 had migraine and 74 were control subjects. Urinary samples were collected into the same plastic container since 8:00 p.m. to 8:00 a.m. of the next day (12-h period) and aMT6s was measured with quantitative ELISA technique. Among patients with migraine, 53% presented pain on the day of the urine samples collection. Their urinary aMT6s concentration was significantly lower than in the urine of patients without pain [14.0 +/- 7.3 vs. 49.4 +/- 19.0; t(143) = -15.1; 95% CI = -40.0 to -30.8; P < 0.001]. There was no significant difference in the aMT6s concentration of patients with migraine without pain on the day of their urine samples collection and controls [49.4 +/- 19.0 vs. 42.5 +/- 27.9; t(140) = 1.7; 95% CI = -1.2 to 14.8; P = 0.094]. To our knowledge, this is the first study to demonstrate reduction in melatonin levels during attacks in episodic and chronic migraine.     

Sleeping behavior and migraine. An evaluation by daily self-reports

PROBLEM: Regarding the coherence of sleeping behavior and the occurrence of migraine attacks, we conducted a study based on migraine and sleeping diaries. METHODS: Besides the daily recording of times of falling asleep and waking up, duration of sleep, sleep disruption and quality of sleep, clinical migraine parameters like occurrence of migraine attacks, headache intensity and duration and the daily mood rating were registered over periods of at least 6 weeks. In the analyses, we defined two classes of events: (1) nights not followed by a migraine attack; (2) nights followed by migraine. We examined a retrospective sample (23 patients with altogether 580 attacks) and a prospective sample (16 patients with altogether 96 attacks). RESULTS: In both samples, we found that the duration of sleep was significantly reduced in nights followed by migraine (6.8 vs. 8.1 h and 6.4 vs. 7.2 h respectively) due to earlier awakening, with unchanged time of falling asleep. Up to two thirds of the observed migraine attacks were reported to be present directly after awakening. Quality of sleep was markedly reduced in nights followed by a migraine attack (i.e. sleep disruptions, feeling exhausted/no feeling of restedness when wakening up). We found only weak and insignificant correlations between the foregoing daily mood rating and the quantitative parameters of sleeping behavior on nights followed by migraine; somewhat more pronounced correlations were observable between the mood rating and the qualitative sleep parameters. CONCLUSIONS: Overall, we conclude that the observed changes in sleeping behavior are largely part of the migraine attack, with the possibility that REM sleep functions as a migraine trigger. In clinical application, we strongly recommend the use of daily self-observations of patients' sleep-related behaviors in the migraine diary, identifying migraine-prone sleeping habits and evaluating their potency for triggering migraine attacks.     

Dysfunction of arousal systems in sleep-related migraine without aura

Primary headaches are closely related to sleep. Modifications in the patterns of arousal during sleep have been reported in migraine, especially in the nights preceding a headache attack. We aimed at evaluating the pattern of arousal from sleep in a group of patients affected by sleep-related migraine. We enrolled 10 consecutive patients, three males and seven females, aged between 20 and 62 years, who presented frequent attacks of migraine without aura (more than five per month), closely related to sleep (more than one-half of the attacks occurred during sleep, causing an awakening). A control group was studied, matched for age and sex. Patients and controls underwent a full-night polysomnographic study, following adaptation; arousal pattern was studied by the scoring of the high-frequency EEG arousal and by the cyclic alternating pattern (CAP). Migraineurs showed a lower CAP rate in non-rapid eye movement (NREM) sleep and, in particular, a lower number of A1 phases (low-frequency, high-amplitude EEG bursts) compared with the controls. Migraineurs also showed a lower index of high-frequency EEG arousals during rapid eye movement (REM) sleep. The reduction in the CAP rate indicates a lower level of arousal fluctuation in NREM sleep. The reduced arousal index in REM suggests a dysfunction in neural structures involved in both the control of REM sleep and the pathophysiology of migraine, such as the hypothalamus and the brainstem.     

A case-control study on excessive daytime sleepiness in episodic migraine

Migraine patients often complain of sleepiness, a problem that manifests both during and outside an attack, may impair the quality of life and can lead to potentially harmful situations. Findings from an uncontrolled study suggest that a high percentage of migraineurs experience excessive daytime sleepiness (EDS). We investigated EDS in a case-control study on 100 patients with episodic migraine and 100 age- and sex-matched healthy controls and also assessed sleep quality, anxiety and depression. Although it was found that EDS was more frequent in migraineurs than in controls (14% vs. 5%; odds ratio 3.1; 95% confidence interval 1.1-8.9), the frequency was lower than previously reported. EDS correlated with migraine disability, sleep problems and anxiety. EDS in patients with migraine probably stems from the full constellation of headache-sleep-affective symptoms resulting from the complex clinical burden of the disease.     

Relationship of endogenous circadian melatonin and temperature rhythms to self-reported preference for morning or evening activity in young and older people.

BACKGROUND: Morningness-eveningness refers to interindividual differences in preferred timing of behavior (i.e., bed and wake times). Older people have earlier wake times and rate themselves as more morning-like than young adults. It has been reported that the phase of circadian rhythms is earlier in morning-types than in evening types, and that older people have earlier phases than young adults. These changes in phase have been considered to be the chronobiological basis of differences in preferred bed and wake times and age-related changes therein. Whether such differences in phase are associated with changes in the phase relationship between endogenous circadian rhythms and the sleep-wake cycle has not been investigated previously. METHODS: We investigated the association between circadian phase, the phase relationship between the sleep-wake cycle and circadian rhythms, and morningness-eveningness, and their interaction with aging. In this circadian rhythm study, 68 young and 40 older subjects participated. RESULTS: Among the young subjects, the phase of the melatonin and core temperature rhythms occurred earlier in morning than in evening types and the interval between circadian phase and usual wake time was longer in morning types. Thus, while evening types woke at a later clock hour than morning types, morning types actually woke at a later circadian phase. Comparing young and older morning types we found that older morning types had an earlier circadian phase and a shorter phase-wake time interval. The shorter phase-waketime interval in older "morning types" is opposite to the change associated with morningness in young people, and is more similar to young evening types. CONCLUSIONS: These findings demonstrate an association between circadian phase, the relationship between the sleep-wake cycle and circadian phase, and morningness-eveningness in young adults. Furthermore, they demonstrate that age-related changes in phase angle cannot be attributed fully to an age-related shift toward morningness. These findings have important implications for understanding individual preferences in sleep-wake timing and age-related changes in the timing of sleep.     

Improving day and night sleep problems in infants by changing day time sleep rhythm: a single group before and after study

This study explores the duration and timing of day time waking periods required for sleep disturbed infants to improve day and night sleep. Seventy-nine sleep disturbed outpatients with day and night sleep problems were investigated before and two weeks after a brief sleep intervention. Data were collected by interviewing parents on their infants’ day and night sleep patterns. Besides instructing the parents on night sleep regulation, they were advised to regulate day sleep. After the intervention, duration of day and night sleep increased and frequency of night waking decreased. The mean duration of the first waking period in the morning did not change, but the range decreased. The mean duration of the last waking period in the evening increased. The frequency of short and irregular day naps and the need for assistance in falling asleep decreased after the intervention. It is recommended that the last waking before night sleep is lengthened to reduce day and night sleep problems.     

Breast-feeding increases sleep duration of new parents

OBJECTIVES: This study describes sleep patterns for mothers and fathers after the birth of their first child and compares exclusive breast-feeding families with parents who used supplementation during the evening or night at 3 months postpartum. METHODS: As part of a randomized clinical trial, the study utilized infant feeding and sleep data at 3 months postpartum from 133 new mothers and fathers. Infant feeding type (breast milk or formula) was determined from parent diaries. Sleep was measured objectively using wrist actigraphy and subjectively using diaries. Lee's General Sleep Disturbance Scale was used to estimate perceived sleep disturbance. RESULTS: Parents of infants who were breastfed in the evening and/or at night slept an average of 40-45 minutes more than parents of infants given formula. Parents of infants given formula at night also self-reported more sleep disturbance than parents of infants who were exclusively breast-fed at night. CONCLUSIONS: Parents who supplement their infant feeding with formula under the impression that they will get more sleep should be encouraged to continue breast-feeding because sleep loss of more than 30 minutes each night can begin to affect daytime functioning, particularly in those parents who return to work.     

Psychophysical Precedents of Migraine in Relation to the Time of Onset of the Headache: The Migraine Time Line

We conducted a prospective study of 19 female migraine patients who kept a diary four times per day at 8 AM, I PM, 6 PM, and 11 PM for 10 consecutive weeks. In the diary, the patients recorded the occurrence as well as the features and associated symptoms of their headaches. They also rated five mood states: alertness, tension, irritability, depression, and fatigue, as well as the quality of sleep and the incidence and stressfulness of daily hassles as measurements of stress. They quantified the variables through the use of 100-mm visual analog scales.
In the diaries, we identified 68 migraine headaches of which 23 developed during the night, 19 during the morning, 16 during the afternoon, and 10 during the evening. The headaches which developed during the evening or night were preceded by an increased incidence of daily hassles during the afternoon. The headaches which developed during the morning or afternoon were preceded by increased tension the previous days.
The day before the headaches which developed during the morning, the incidence of daily hassles was increased during the morning, afternoon, and evening. The increased tension at I PM was followed by increased fatigue at 6 PM, which was still present at 8 AM of the morning during which the headaches developed. The day before the headaches which developed during the afternoon, the increased tension at 6 PM was followed by increased alertness at 11 PM. The next morning, the stressfulness of daily hassles was increased at 8 AM, followed by increased tension and irritability at 1 PM.
We conclude that there are three different sequences of events with regard to the psychophysical precedents of migraine, depending on the time of onset of the headache: the migraine time line.     

Quality of sleep, fatigue and daytime sleepiness in migraine— a controlled study

The objective of this study was to evaluate whether the quality of sleep and the degree of fatigue and daytime sleepiness are related to migraine. We investigated 489 subjects comprising 97 patients with eight or more, 77 patients with five to seven and 196 patients with one to four migraine days per month, and 119 migraine-free controls with fewer than six headache days per year. The patients were recruited via articles in newspapers not stressing the subject of the study. All participants underwent a semistructured interview and completed the Pittsburgh Sleep Quality Index (PSQI), the Fatigue Severity Scale (FSS), the Epworth Sleepiness Scale (ESS) and the Self-rating Depression Scale and the Self-rating Anxiety Scale. For statistical analysis we used two way manova s, post hoc univariate two-way anova s and Hochberg's GT2 tests as well as three-way mixed design anova s. The PSQI total score was highest in patients with frequent migraine (5.9 ± 4.3) and lowest in controls (4.3 ± 2.5, P  = 0.04). Four subscores of the PSQI showed similar statistically significant differences. The FSS and ESS scores did not differ in the four study groups. Analysing depression and anxiety revealed a significant impact on PSQI, FSS and ESS, but did not demonstrate interactions with migraine, thus suggesting that the impact of migraine is similar in patients without and with psychiatric comorbidity. In conclusion, the quality of sleep is decreased in patients with migraine, whereas fatigue and daytime sleepiness do not differ from healthy controls. The decreased quality of sleep in migraineurs is also a consequence of migraine itself and cannot be explained exclusively by comorbidity with depression or anxiety.     

“早太极、晚八段”对社区2型糖尿病失眠患者睡眠质量的影响

目的：观察“早太极、晚八段”的中医运动养生法对社区2型糖尿病失眠患者睡眠质量的干预效果。方法：将62例社区2型糖尿病伴失眠患者以社区为单位随机分为试验组32例和对照组30冽,在常规治疗基础上,试验组采用“早太极、晚八段”的中医运动养生法进行干预,对照组每天进行步行锻炼。结果：试验组患者失眠疗效高于对照组（P〈0．05）,匹兹堡睡眠质量指数低于对照组（P〈0．05）。结沦：“早太极、晚八段”的中医运动养生法对2型糖尿病失眠患者睡眠质量有一定的改善作用。     

Combined use of zolpidem and enalapril in elderly patients with essential arterial hypertension and sleep problems

Changes in 24-h profiles of arterial pressure following treatment with zolpidem were studied in 12 patients with essential arterial hypertension and chronic sleep problems on enalapril. One week treatment with zolpidem improved quality of sleep, increased a circadian index of systolic arterial pressure, 3 non-dipper patients recovered circadian rhythm of arterial pressure. The antihypertensive effect at night was higher when enalapril was used in combination with zolpidem than in monotherapy with enalapril.     

What Can Precipitating Factors Teach us About the Pathogenesis of Migraine?

SYNOPSIS
Relationships between precipitating factors in the pathogenesis of migraine were studied in a sample of 217 migraineurs. The most frequently cited triggers were the menstrual cycle (51.5% of the women), alcoholic beverages (51.6%) and emotional or psychic stress (48.8%). Analysis of 4 subgroups of patients, i.e. those with only one of these 3 triggers or with none of these (controls), showed that alcohol-susceptible patients reported significantly (p<0.001) more alimentary triggers than the controls. A similar phenomenon was found in patients with menstrual-cycle related migraine, but in this group the difference with the controls fell short of reaching statistical significance. A further analysis showed that menstrual migraine attacks are more frequently preceded by depressive symptoms than other migraine attacks.
It is suggested that the gut of certain migraineurs may be unduly permeable, either intrinsically or extrinsically (e.g. under the influence of alcohol). In addition, in some patients with menstrual migraine, a depressive episode, associated with the menstrual period, may facilitate the development of a migraine attack.     

How to use light and dark to produce circadian adaptation to night shift work.

The circadian rhythms of night shift workers do not usually adjust to their unusual work and sleep schedules, reducing their quality of life and producing potentially dangerous health and safety problems. This paper reviews field studies of simulated night work in which shifted light-dark cycles were constructed with artificial bright or medium-intensity light to produce circadian adaptation, ie the shifting of circadian rhythms to align with night work and day sleep schedules. By using these studies we describe fundamental principles of human circadian rhythms relevant to producing circadian adaptation to night shift work at a level designed for the reader with only a basic knowledge of circadian rhythms. These principles should enable the reader to start designing work/sleep-light/dark schedules for producing circadian adaptation in night shift workers. One specific schedule is presented as an example. Finally, we discuss phase-response curves to light and clarify common misconceptions about the production of circadian rhythm phase shifts.