"What's novel in our study is the finding that a high percentage of patients with headache have sleep disturbance," says Kenneth Mack, M.D., Ph.D., pediatric neurologist specializing in headache and the senior study investigator. "The number of patients who have headaches and also sleep disturbance surprised us. They also have the same sleep disturbance: a delay in sleep onset."
The researchers undertook this study to scientifically study their observation in the clinic that many children suffer from both headaches and sleep problems.
"We've continually seen that children with headaches are poor sleepers and that they're fatigued because they have poor sleep," says Dr. Mack. "We've known that when people don't get enough sleep they get more headaches, but we'd not appreciated the frequency of sleep disturbance with chronic daily headache."
The study involved a retrospective chart review of 100 children ages 6 to 17 with chronic daily headache -- headache present 15 or more days a month for three months or more -- and 100 children in the same age category with episodic headache -- headache that occurs with less frequency than chronic daily headache. In addition to sleep onset delay, sleep problems found in children studied included awakening during the night or too early in the morning, or not feeling refreshed after sleep.
The investigators do not yet know which problem comes first -- sleep problems or headache. In some children sleep problems come first, and in others, headache is first. "They feed on each other: sleep problems make the headaches worse, and the headaches make the sleep problems worse," says Dr. Mack. "Also, the worse the headaches, the more likely children are to have sleep problems, and vice versa. They could have a common cause, or one problem could be an early sign of the other."
Treatment must be simultaneous for both conditions, using medicine and non-medicine approaches, says Dr. Mack. "It's going to be hard to control the headaches till you get the sleep problems under control either with medication or non-medication treatment," he says.
Key non-medication treatments include attention to maintaining routine in the child's schedule and developing good sleep hygiene, according to Lenora Lehwald, M.D., Mayo Clinic neurology resident and study investigator. "Educating the patient and family on things like good sleep habits may in and of itself help to improve the sleep quality and thus the headaches in the long run," she says.
Dr. Lehwald explains that good sleep hygiene for children involves what seem to be very basic and simple practices in the evening routine. "A child should use his bedroom for just the types of activities that would be sedating and relaxing," she says. "TVs, video games -- things that are exciting and get the child interested, motivated and activated -- should not be in the bedroom. Also, it's important for children to have a routine for calming down and preparing for sleep the last hour they plan to be awake. They should choose activities that make them drowsy, like reading."
If a child with both headache and sleep problems requires medicine, Dr. Mack prefers migraine medication that also helps with sleep issues.
Addressing sleep problems in children who have episodic headache may also avert the child's transition to chronic daily headache, according to Dr. Lehwald. Children who develop chronic daily headache typically have had episodic headache.
Age is one factor that puts children at risk for headache. Teenagers have the highest level of risk, according to Dr. Mack, which may be partly due to a higher stress level for teens than for younger children. He also notes that a typical teen needs about 9.5 hours of sleep per night, more than most teens get. Family history of headache, time of year and stress level also appear to impact headache risk, say the researchers.
"Fall, when children start school, is a stressful time for children, and it's very much a time when they will experience more headache," says Dr. Lehwald. "As school lets up in the summer, they seem to have more headache-free time. So, that's a good indicator that stress has an impact on the frequency and severity of children's headaches."
From 10 to 20 percent of children have episodic headache. Chronic daily headache occurs in up to 4 percent of girls and up to 2 percent of boys.
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