Effects of Sleep Duration on Classic Migraine and Depression Headache Pain: Case Reports

Headache etiology research has not supported the traditional headache classification system. This paper provides evidence that classic migraine headache and muscle contraction headaches that appear in the morning (depression headaches) may share a common etiology and respond to the same treatment—reducing sleep duration. Three clinical cases with long-standing headaches are presented, one a depression headache patient and two classic migraineurs. All case histories showed a strong relationship between extended sleep duration and headaches, and headaches completely remitted after patients consistently awakened one-half to one hour earlier than their normal rising time. Eight common migraineurs showed no such relationship and failed to respond to sleep manipulations.

We conclude that classic migraine and morning onset “muscle contraction” (or depression) headaches may result from serotonergic mechanisms which are triggered by excessive sleep. Common migraines, in contrast, may be related to oral habits and temporomandibular joint derangement.     

Headaches and their relationship to sleep.

Despite the complex influences of normal sleep physiology and sleep disorders on the development or presentation of headache, it is important to recognize and understand these relationships. Successful outcomes depend on the provision of treatment interventions specifically directed toward each condition. Nocturnal or early morning headaches that are associated with OSA are often eradicated after the sleep disorder is successfully managed with CPAP, oral appliances, or surgery. Substantial improvement in headache can also result from the successful management of other sleep disorders that may incite headaches such as heavy snoring, PLMS, or the various forms of insomnia. To improve headache patterns associated with bruxism and TMD, it is often necessary to formulate a multidisciplinary treatment approach that combines oral appliance therapy, stress management, biofeedback, oromandibular physical therapy, and, at times, pharmacologic treatment (i.e., tricyclic antidepressant, intramuscular botulinum toxin injections). There are still many gaps in the understanding of the interrelationships of sleep physiology and headache pathophysiology. More well-designed clinical trials are needed so that enough data can be amassed for the formulation of evidence-based guidelines or consensus statements that can better delineate the identification, diagnostic evaluation, and treatment of sleep-related headache disorders and headaches that develop as a consequence of disordered sleep.     

Association between masseter muscle activity levels recorded during sleep and signs and symptoms of temporomandibular disorders in healthy young adults

AIMS: To examine whether any signs and symptoms of temporomandibular disorders were significantly associated with masseter muscle activity levels during sleep. METHODS: One hundred three healthy adult subjects (age range, 22 to 32 years) participated in the study. They were asked to fill out questionnaires, undergo a calibrated clinical examination of their jaws and teeth, and perform 6 consecutive nightly masseter electromyographic (EMG) recordings with a portable EMG recording system in their home. The EMG data were considered dependent variables, while the questionnaire and examination data were considered independent variables. Multiple stepwise linear regression analysis was utilized to assess possible associations between these variables. RESULTS: Both gender and joint sound scores were significantly related to the duration of EMG activity. None of the other independent variables were found to be related to any of the muscle activity variables. CONCLUSION: The results suggest that both gender and clicking are significantly related to duration of masseter EMG activity during sleep.     

Masticatory muscle activity as a function of parafunctional, active and passive oral behavioural patterns

Oral behavioural patterns have received limited empirical support for their causal role in the development of head and facial pain. The present study was designed to assess electromyographic (EMG) variations in six muscle groups (i.e., bilateral masseter, temporalis and orbicularis oris) as a function of various oral behavioural patterns. A second purpose was to determine whether mandibular movement patterns and specific oral behaviours could be predicted by EMG patterns. Eleven non-pain subjects followed each of twenty oral behavioural patterns while EMG was recorded. Electromyographic change scores were computed for each behaviour relative to baseline measures. Initial analyses were performed using factorial repeated measures ANOVAS. Using post hoc analyses as general guides, specific EMG criteria were developed for classifying mandibular movements. For most subjects, EMG patterns accurately classified teeth clenching, protrusive/retrusive movements, right movements, left movements and lip movement patterns. Wide individual variations were found among muscle groups for identical behaviours. The association between particular oral behaviours and EMG patterns may explain 'sinus' headaches and certain types of facial pain.     

Tooth wear and bruxism: a sleep laboratory investigation

This pilot investigation was concerned with the study of bruxing patterns during sleep of five young subjects each representing a dental treatment category showing a distinct level of tooth wear. Electroencephalogram (EEG), electrooculogram (EOG), and electromyogram (EMG) activity was recorded on two consecutive nights. All five sleep profiles were very similar to the established norms for their age group. It was observed that EMG disturbances which may be associated with bruxing occurred in all sleep stages but predominantly in Stage 2 and rapid eye movement (REM) sleep. There were no systematic differences in EMG disturbances related to different levels of dental treatment and tooth wear.     

Effects of food consistency on sleep and wakefulness in rats

The present study examined the effects of food consistency, i.e., pelleted vs. powdered food, on the amount of REM and non-REM sleep, and wakefulness in rats fed with either type of food for 2 weeks. Polysomnography included neck muscle electromyogram (EMG), delta and spindle waves of the frontal electroencephalogram (EEG) and theta waves of the parietal EEG. We found that the amount of non-REM sleep during the dark period, when the rats were active, was significantly lower in rats fed the powdered food compared with those fed the pelleted food. This finding was most marked at the start of the dark period. Wakefulness was also longer in rats fed the powdered food during the dark period. The results indicate that food consistency affects non-REM sleep and wakefulness in rats, and that these effects may be related to changes in mastication.     

Masticatory muscle activity assessment and reliability of a portable electromyographic instrument

STATEMENT OF PROBLEM: Masticatory muscle hyperactivity is thought to produce muscle pain and tension headaches and can cause excessive wear or breakage of restorative dental materials used in the treatment of prosthodontic patients. The quantification and identification of this type of activity is an important consideration in the preoperative diagnosis and treatment planning phase of prosthodontic care. PURPOSE: This study investigated the quantification process in complete denture/overdenture patients with natural mandibular tooth abutments and explored the reliability of instrumentation used to assess this parafunctional activity. MATERIAL AND METHODS: The nocturnal EMG activity in asymptomatic complete denture/overdenture subjects was assessed with and without prostheses worn during sleep. Because of the large variance within and between subjects, the investigators evaluated the reliability of the 3 instruments used to test nocturnal EMG activity in the sample. RESULTS: Electromyographic activity data of denture/overdenture subjects revealed no differences between prostheses worn versus not worn during sleep but demonstrated a very large variance factor. Further investigation of the instrumentation demonstrated a consistent in vitro as well as in vivo reliability in controlled laboratory studies. CONCLUSION: The portable EMG instrumentation used in this study revealed a large, uncontrollable variance factor within and between subjects that greatly complicated the diagnosis of parafunctional activity in prosthodontic patients.     

Mastication of model products in complete denture wearers

OBJECTIVE: The aim of this study was to define the characteristics of muscular activity in complete denture wearers and in dentate subjects during mastication of model foods differing in hardness but similar in terms of rheologically properties. MATERIAL AND METHODS: The foodstuffs used in this study were laboratory-developed gumdrops demonstrating viscoelastic properties. The test foods cover a range of four hardness levels. The group of complete denture wearers included 15 subjects, while the control group included 9 subjects with normal dentition. Electromyograph (EMG) recordings were taken from the masseter and temporal muscles during mastication of the test foods. The results were evaluated by one-way and two-way ANOVA followed by means comparisons using a Student-Newman-Keuls post hoc test (alpha=0.05). RESULTS: Preparing the same food bolus for swallowing required a greater number of masticatory cycles and a longer duration of mastication for complete denture wearers than for dentate subjects. In addition, complete denture wearers failed to increase EMG activity per cycle in response to hardness of the food. CONCLUSION: Denture wearers experienced difficulties during mastication, as indicated by a decreased masticatory rate and the observed failure to increase EMG activity per cycle in response to increased food hardness. The increases in number of cycle and masticatory duration appear to be a response to this impaired masticatory function.     

Influence of functional appliances on masticatory muscle activity

The purpose of the present study was to investigate the influence of an activator appliance and a spring active appliance on masticatory muscle activity by means of electromyography (EMG). Twelve adult males with good general health were recruited as subjects. Three functional appliances were used in each subject for long-period EMG recording during daytime and sleep and short-time EMG recording during voluntary biting. Following findings were obtained. (1) The activity of all muscles was greater during biting than during daytime and sleep, (2) the muscle activities tended to increase in the digastric muscle and to decrease in the temporal muscle with activators under all conditions, and (3) the temporalis-masseter ratios became lower with the biting use of appliances. Therefore, this study suggests that functional appliances should be used during sleep and during the day in combination with voluntary biting to achieve adaptation and development of the masticatory muscles.     

Association between the amount of alcohol intake and masseter muscle activity levels recorded during sleep in healthy young women

PURPOSE: The aim of this study was to determine if the amount of alcohol intake is associated with masseter muscle activity recorded during sleep. MATERIALS AND METHODS: Sixty healthy young female subjects (average age, 23.0 +/- 1.9 years; range, 21 to 32 years) participated in the study. Subjects were asked to perform 6 consecutive nightly masseter electromyography (EMG) recordings by using a portable EMG recording system in their homes. Using a minimum threshold criterion, which was set at 20% of the maximum voluntary contraction level, the total duration of muscle activity per hour of sleep was calculated. EMG data obtained on the first night were excluded from the analysis to avoid the first-night effect, and the data of the remaining 5 nights were averaged. Further, the subjects were asked to fill out questionnaires regarding their daily alcohol intake during the recording period. The total ethanol content of the consumed alcohol was calculated using a standard conversion table for alcoholic beverages. The ethanol concentration of each type of alcohol was multiplied by the reported amount consumed on each day, and the average value for 5 days was calculated. The EMG data were considered as a dependent variable, while the alcohol data were considered as an independent variable. Linear regression analysis was used to assess a possible association between these variables. RESULTS: The subjects who did not consume alcohol during the recording period (n = 28) or who provided incomplete data sets as a result of missing data (n = 9) were excluded. The data of the remaining 23 subjects (n = 23) were exclusively analyzed. The result of this analysis revealed that the total ethanol content of the consumed alcohol was significantly and positively related to the EMG duration variable (coefficient = 0.51, 95% confidence interval: 0.20 to 0.82, adjusted R2 = 0.33, P < .01). CONCLUSION: The results suggest that the amount of alcohol intake is substantially associated with masseter muscle activity levels during sleep in young women.     

The relationship between selective sleep deprivation, nocturnal jaw-muscle activity and pain in healthy men

The relationship between nocturnal jaw-muscle activity and temporomandibular disorders (TMD) is still controversial. The aim of this study was to investigate the effect of selective slow wave sleep (SWS = non-rapid-eye-movement (NREM) stage 3 + 4) deprivation on jaw-muscle activity using a new automatic system. Ten healthy men without signs of symptoms of TMD participated. The subjects slept in the laboratory for six continuous nights including one adjustment night, one baseline night, three nights with experimental sleep deprivation and one recovery night. Polysomnographic recordings of electroencephalography (EEG) and electromyography (EMG) were obtained for recognition of sleep stages and masseter muscle activity. During the three experimental nights, computer-controlled sound stimulation (60--90 dB(A), 1000 Hz) were given as long as the subjects were in SWS. Maximum voluntary occlusal force (MVOF), pain pressure threshold (PPT) and visual analogue scales (VAS) were used to assess the state of the masseter muscles every morning and evening during the study period. The results showed that the time spent in SWS was significantly decreased during the first sleep deprivation night, but there were no significant effects on nocturnal EMG activity (i.e. the numbers of bruxism episodes per hour of sleep, bruxism bursts per episodes bruxism bursts per hour of sleep), MVOF, VAS or PPT. Furthermore, the automatic system only deprived the SWS in five subjects for the following two nights although the sound stimulation was given at the maximum intensity. These results suggest that deprivation of SWS may not interact immediately with nocturnal jaw-muscle activity and jaw-muscle pain.     

Craniofacial pain and jaw-muscle activity during sleep

This study compared the jaw-muscle electromyographic (EMG) activity during sleep in patients with craniofacial pain (n = 63) or no painful conditions (n = 52) and between patients with tension-type headache (TTH: n = 30) and healthy control individuals (n = 30). All participants used a portable single-channel EMG device (Medotech A/S) for four nights. There was no significant difference in EMG activity between craniofacial pain (24.5 ± 17.9 events/hr) and no painful conditions (19.7 ± 14.5), or between TTH (20.8 ± 15.0) and healthy control individuals (15.2 ± 11.6, p >.050). There were positive correlations between EMG activity and number of painful muscles (r = 0.188; p = 0.044), characteristic pain intensity (r = 0.187; p = 0.046), McGill Pain Questionnaire (r = 0.251; p = 0.008), and depression scores (r = 0.291; p = 0.002). Patients with painful conditions had significantly higher night-to-night variability compared with pain-free individuals (p < 0.050). This short-term observational study suggests that there are no major differences between patients with different craniofacial pain conditions and pain-free individuals in terms of jaw-muscle EMG activity recorded with a single-channel EMG device during sleep. However, some associations may exist between the level of EMG activity and various parameters of craniofacial pain. Longitudinal studies are warranted to further explore the relationship between sleep bruxism and craniofacial pain.     

Validity of a brief questionnaire in screening asymptomatic subjects from subjects with tension-type headaches or temporomandibular disorders

Abstract Clinical investigations of temporomandibular disorders require objective, repeatable methods for screening diseased subjects from non-diseased control subjects. This study evaluated whether information gathered from a short, public domain questionnaire was useful in distinguishing temporomandibular disorder subjects (n= 216) from non-temporomandibular disorder controls (n= 69) and tension-type headache subjects (n= 22). The questionnaire consisted of eight questions relating to jaw pain (i.e., location of pain, precipitating factors, and temporal pattern of pain) and five questions relating to jaw function (i.e., joint noises, locking, and difficulty in opening). There were five possible answers to each question which ranged from 0 (no symptoms) to 4 (unbearable or constant symptoms). The total scores for the eight pain questions and the five jaw function questions were used to determine the questionnaire's sensitivity and specificity in each group, and ROC curves were plotted to identify the best cutoff point for disease presence or absence. Results showed that the questionnaire reliably distinguished between the control group and tempormandibular disorder group with 90.3% 97.7% sensitivity and 95.7%–100% specificity at cutoff values between 5 and 9. These results support the use of the questionnaire as a primary screening tool for general practice and as a supplementary screening tool for clinical temporomandibular disorder studies. However, results also showed that the questionnaire was unable to distinguish easily between TMD subjects and temporalis region tension-type headache subjects.     

Rhythmic masticatory muscle activity during sleep in humans

Rhythmic Masticatory Muscle Activity (RMMA) is frequently observed during sleep in normal subjects and sleep bruxers. We hypothesized that some normal subjects exhibit RMMA at a lower frequency than sleep bruxers. Polysomnographic data from 82 normal subjects were compared with data from 33 sleep bruxers. RMMA episodes were defined as three or more consecutive bursts of masseter EMG activity, with or without tooth-grinding. Such episodes were observed in nearly 60% of normal subjects. A lower frequency of episodes was noted in normal subjects than in bruxers. Sleep organization was similar between groups. Bruxers had twice as many masseter muscle bursts per episode and episodes of higher amplitude compared with controls with RMMA. The high prevalence of RMMA observed in normal subjects suggests that this activity is related to certain sleep-related physiological functions, including autonomic activation.     

Different substances and dry-needling injections in patients with myofascial pain and headaches

Trigger point injections with different solutions have been studied mainly with regard to the management of myofascial pain (MFP) patient management. However, few studies have analyzed their effect in a chronic headache population with associated MFP. The purpose of this study was to assess if trigger point injections using lidocaine associated with corticoid would be better than lidocaine alone, as in comparison with dry-needling in for the management of local pain and associated headache management. Forty-five (45) myofascial pain patients with headaches that could be reproduced by activating at least one trigger point, were randomly assigned into one of the three groups: G1, dry-needling, G2, 0.25% lidocaine, at 0.25% and G3, 0.25% lidocaine at 0.25% associated with corticoid, and were assessed during a 12 week period. Levels of pain intensity, frequency and duration, local post-injection sensitivity, obtainment time and duration of relief, and the use of rescue medication were evaluated. Statistically, all three groups showed favorable results for the evaluated requisites (p < or = 0.05), but only for post-injection sensitivity did the association of lidocaine with corticoid present the best results and ingestion of rescue medication.     

Validity and reliability of a protocol of orofacial myofunctional evaluation for patients with obstructive sleep apnea

There is no standardized protocol for the clinical evaluation of orofacial components and functions in patients with obstructive sleep apnea. The aim of this study was to examine the validity, reliability, and psychometric properties of the Expanded Protocol of Orofacial Myofunctional Evaluation with Scores (OMES‐expanded) in subjects with obstructive sleep apnea. Patients with obstructive sleep apnea and control subjects were evaluated, and the validity of OMES‐expanded was tested by construct validity (i.e. the ability to discriminate orofacial status between apneic and control subjects) and criterion validity (i.e. correlation between OMES‐expanded and a reference instrument). Construct validity was adequate; the apneic group showed significantly worse orofacial status than did control subjects. Criterion validity of OMES‐expanded was good, as was its reliability. The OMES‐expanded is valid and reliable for evaluating orofacial myofunctional disorders of patients with obstructive sleep apnea, with adequate psychometric properties. It may be useful to plan a therapeutic strategy and to determine whether the effects of therapy are related to improved muscle and orofacial functions.     

Dental stability and maximal masticatory muscle activity

The electromyographical (EMG) activity of masticatory muscles during full clenching in the retruded contact position (RCP) and intercuspal position (IP) with and without a posterior stabilizing splint was studied. The linear envelope EMG signal from three bilateral muscles was recorded (masseter, anterior temporal and posterior temporal). Thirty-seven subjects were evaluated. Clenching in the RCP without the splint and with the presence of an unstable occlusal contact inhibited the masseter muscle activity and reduced anterior temporal and posterior temporal muscle activity. The masticatory muscle activity returned to normal when clenching in the RCP with a splint that permitted stability in the dentition. EMG activity was the same in the IP with and without the splint. The results indicate that the determinant of maximal masseter isometric muscle contraction is the amount of stability in the dentition rather than the jaw position. If the dentition takes the major role of stabilizing the mandible, i.e., there is good intercuspation, the masseter muscle can exert maximal isometric contraction. If the stability is not provided by the dentition, i.e., there is a premature contact, the jaw muscles must contribute to the stabilization and reduce the magnitude of the maximal contraction to avoid damage to the structures involved in the compensatory stabilization.     

Nocturnal masseter EMG activity of healthy subjects in a natural environment.

Facial pain of patients with craniomandibular disorders might be caused by muscle overload. However, the activity of masticatory muscles of healthy individuals is still unknown. The aim of this study was therefore a first attempt to clarify this question by recording the masseter muscle activity of healthy subjects during sleep by means of portable recorders. The study was performed on 21 healthy subjects selected after telephone and questionnaire screenings and clinical examination from among randomly selected inhabitants of Zürich. The masseter EMG was recorded during seven nights in each subject's natural environment with the electrodes in reproducible position. The signal was analyzed for number, amplitude, and duration of contraction periods defined as signal portions above a threshold which could contain sub-threshold signal portions shorter than the standby time of 5 sec. The signal amplitude was expressed in percent of the amplitude recorded during maximum voluntary clenches (%MVC). An average of 71.9 +/- 28.7 contraction episodes per night (men, 74.7 +/- 30.1; women, 65.0 +/- 23.8; p = 0.043), i.e., of 10.5 +/- 3.8 per hour (men, 11.0 +/- 4.0; women, 9.3 +/- 3.0; p = 0.005), was found. The average mean amplitude was 26.2 +/- 6.4% MVC (men, 27.0 +/- 6.8; women, 24.4 +/- 4.5; p = 0.009). The duration of the episodes had a mode of 0.5 sec, and the group mean of the integral of the amplitude over time was 123.7 +/- 157.9% MVC (men, 138.9 +/- 184.0; women, 85.9 +/- 28.2; p = 0.005). Healthy subjects showed intermittent periods of masseter activity during sleep which, on average, were of rather low intensity and short duration.     

Assessment of sleep parameters during contingent electrical stimulation in subjects with jaw muscle activity during sleep: a polysomnographic study

There is emerging evidence that feedback techniques based on contingent electrical stimulation (CES) have an inhibitory effect on the electromyogram (EMG) activity of jaw-closing muscles and therefore could be useful in the management of sleep bruxism. This polysomnographic (PSG) study was designed to investigate the effect of CES on PSG parameters in subjects with self-reported bruxism. Fourteen subjects underwent a full PSG investigation in the laboratory for three consecutive nights - one night of adaptation, one night without CES, and one night with CES - in a randomized order. During all sessions the EMG activity was recorded by a portable feedback device from the temporalis muscle. An electrical pulse, which was adjusted to a moderate, but non-painful, intensity, was applied to subjects during the session with CES, if jaw-muscle activity was detected. The total sleep time, the number of micro-arousals per hour of sleep, the time spent in sleep stages 3 and 4 and in rapid eye movement (REM) sleep, and the number of periodic limb movements, were not influenced by CES. The number of EMG episodes per hour of sleep during the nights with and without CES was not significantly different. The present study suggests that CES at non-painful intensities does not cause major arousal responses in any of the sleep parameters assessed in this study.     

Agreement between clinical and portable EMG/ECG diagnosis of sleep bruxism

The aim of this study was to compare clinical sleep bruxism (SB) diagnosis with an instrumental diagnosis obtained with a device providing electromyography/electrocardiography (EMG/ECG) recordings. Forty‐five (N = 45) subjects (19 males and 26 females, mean age 28 ± 11 years) were selected among patients referring to the Gnathology Unit of the Dental School of the University of Torino. An expert clinician assessed the presence of SB based on the presence of one or more signs/symptoms (i.e. transient jaw muscle pain in the morning, muscle fatigue at awakening, presence of tooth wear, masseter hypertrophy). Furthermore, all participants underwent an instrumental recording at home with a portable device (Bruxoff^®; OT Bioelettronica, Torino, Italy) allowing a simultaneous recording of EMG signals from both the masseter muscles as well as heart frequency. Statistical procedures were performed with the software Statistical Package for the Social Science v. 20.0 (SPSS 20.0^®; IBM, Milan, Italy). Based on the EMG/ECG analysis, 26 subjects (11 males, 15 females, mean age 28 ± 10 years) were diagnosed as sleep bruxers, whilst 19 subjects (7 males, 12 females, mean age 30 ± 10 years) were diagnosed as non‐bruxers. The correlation between the clinical and EMG/ECG SB diagnoses was low (ϕ value = 0·250), with a 62·2% agreement (28/45 subjects) between the two approaches (kappa = 0·248). Assuming instrumental EMG/ECG diagnosis as the standard of reference for definite SB diagnosis in this investigation, the false‐positive and false‐negative rates were unacceptable for all clinical signs/symptoms. In conclusion, findings from clinical assessment are not related with SB diagnosis performed with a portable EMG/ECG recorder.