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A study
that examined the sleep of women living with heavy snorers found that these
women, in addition of suffering disturbed sleep and daytime sleepiness, also had
morning headaches.
Other
studies also reported associations between morning headaches and periodic limb
movement disorders.
Morning
headaches were also found in hypertension.
Prior to our study, the prevalence of
morning headaches in the general population was not known, although according to
a Swedish study, 5% of the population awakened often or very often with
headaches.
Methods
The studied countries were:
-
the
United Kingdom,
-
Germany,
-
Italy,
-
Portugal
and
-
Spain.
This represented about 206 million
Europeans.
A two-stage design was used for all countries.
The population of each
country was:
-
first divided according to its geographical
distribution as per the official census data, then
telephone numbers were randomly drawn in each geographical area.
-
Second,
within each household, a member was selected by age and gender using the Kish
method (17) in order to maintain the representation of the
sample and to avoid bias related to non-coverage error.
Participants had to first grant their verbal consent prior to proceeding with
the interview.
We excluded potential participants who had insufficient fluency
in the national language, who had a hearing or speech impairment or with an
illness that precluded the feasibility of an interview.
The participation rate was:
-
79.6% (4,972 of 6,249 eligible individuals) in the
UK;
-
8.1%
(4,115 of 6,047 eligible individuals) in Germany;
-
89.4%
(3,970 of 4,442 eligible individuals) in Italy;
-
83%
(1,858 of 2,234 eligible subjects) in Portugal;
-
and
87.5% (4,065 of 4,648 eligible individuals) in Spain.
A total
of 18,980 subjects participated in the study.
The
overall participation rate was 80.4%.
Results
This study is the first to explore the associated factors of morning headaches
in the general population using a large sample (N=18,980 subjects).
We found a prevalence of
7.6% of subjects who said they woke up at least sometimes with headaches, with a
median duration in which they occurred of 42 months.
Our study is not without shortcomings.
The
primary purpose of these community-based surveys was to investigate sleep and
mental disorders.
Therefore, full description of the headaches, the localization and the intensity
of the pain were not assessed.
A study that attempted to
classify morning headaches into the different categories of headaches (migraine,
tension-type, cluster, cervicogenic headaches) was unable to fit nearly half of
the patients with morning headaches into one of these categories (2).
Risk factors related to morning headaches
were examined according to five main categories:
sociodemographic determinants,
use of psychoactive substances, organic diseases, sleep disorders and mental
disorders:
Socio-demographic determinants of morning headaches
Among sociodemographic
determinants, we found that:
were positively related to morning headaches.
A study that examined the frequency of morning headaches in a community-based
sample did not find significant differences between men and women, but limited
the analysis to subjects with heavy snoring and obstructive sleep apnea syndrome
(1).
Psychoactive substances and morning headaches We also found a positive association:
Subjects using these psychoactive substances were twice as likely to report
morning headaches.
In the studies that analyzed factors related to morning
headaches, these two factors were rarely taken into account, although these
two psychoactive substances have well-known depressive effects on the
respiratory system.
Lack of sufficient oxygenation during sleep may favor the
occurrence of headaches upon awakening.
Organic disorders and morning headaches Among organic disorders, we found that:
-
subjects with hypertension or musculo-skeletal diseases had a higher risk of
reporting morning headaches.
-
Changes in blood pressure are likely to cause
headaches.
Hypertensive headaches do not have specific diagnostic features,
but are known to be most pronounced on awakening in the morning (26).
However,
as the results showed, the presence of hypertension alone is not sufficient to
explain the presence of morning headaches: not all subjects with morning
headaches have hypertension and conversely not all subjects with hypertension
reported morning headaches.
Heavy snoring/Obstructive Sleep Apnea Syndrome and
morning headaches
OSAS
limits the airflow during sleep, causing repeated episodes of hypoxia. It also
causes alterations in blood pressure control mechanisms.
These two mechanisms
can provoke headaches during sleep that may still be present upon awakening.
Many believe that morning headaches are specific to sleep breathing disorders.
This assertion is based on clinical trials that report reduction of the
severity of morning headaches in OSAS patients treated with continuous
positive airway pressure (2).
However, most of these studies lack adequate
control groups and/or assessment of possible confounders to provide strong
support to whether morning headaches are specific to OSAS.
Our results do not
support the uniqueness of this association.
We did find that obstructive sleep
apnea syndrome and heavy snoring made an independent contribution to morning
headaches, but they were neither the only nor the strongest predictors of
morning headaches.
Other studies also reported the non-specificity of morning
headaches to sleep breathing disorders (27,28).
Other sleep disorders and morning
headaches
In
our study, we extended the
associations to other diseases and disorders that may influence the occurrence
of morning headaches.
Among sleep disorders, we found that:
-
dyssomnia not otherwise
specified, which included restless legs syndrome, periodic limb movement
disorder and sleep disorders with multiple possible causes, had the highest
association with morning headaches.
-
The association between morning headaches
and insomnia disorders or other sleep disorders involving a lack of sleep is
not so surprising because sleep deprivation is a well-known cause of headaches
(29).
Major Depressive Disorder and morning headaches
We also found that subjects with a major
depressive disorder were at high risk of waking up with headaches.
This disorder had one of the highest odds ratios in the multivariate model.
Our data are cross-sectional, therefore, we cannot make causal reference between
the morning headaches and depression.
Some longitudinal studies also had explored the association between depression
and migraine or chronic headaches.
For example, Breslau et al. (14) found that subjects with migraine and those
with severe headaches were three times more likely to have a major depression
in their lifetime and conversely, subjects with migraine or severe headache
were two to three times more likely to later develop a major depression.
Similarly, in a longitudinal study, Pine et al. (15) reported that adolescents
with major depression at the first evaluation had nearly a tenfold increased
risk of developing headaches during the next seven years.
It
appears the associated migraine-depression is a bi-directional relationship;
the presence of one increasing the risk of appearance of the other.
However, to what extent waking up with headaches is related to depressive
disorders is little documented. It is likely that the relationship is similar to
that reported for migraine or severe headache and depression: morning headaches
can be a somatic manifestation of depression or morning headaches can be a cause
of depression.
Conclusion
Subjects with headaches almost all have either an organic disease or a sleep or
a mental disorder, but most often several factors are involved.
Our
results clearly show that it is misleading to relate morning headaches only to
sleep-related breathing disorder.
An
effort should be made to better describe morning headaches in subjects with
obstructive sleep apnea before concluding to the specificity of this
association.
Recurrent morning headaches in about 80% of cases are related to an identifiable
organic, mental or sleep disorder.
Therefore, physicians should be aware of the multiplicity of factors involved in
the complaint of morning headaches and the necessity of conducting a thorough
interview with the patient to identify all possible factors, because it is most
likely that many factors are involved.
Content of this page
is extracted from
Ohayon MM.,
Prevalence and risk factors of morning headaches in the general population.
Arch Intern Med. 2004 Jan 12;164(1):97-102.
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