When I see a patient for a sleep consultation, I always ask whether they wake with headaches. If so, this indicates a high suspicion for obstructive sleep apnea. Patients who wake with headaches are three times more likely than the general population to be heavy snorers or to experience obstructive sleep apnea (OSA).1
The patient with possible OSA will say that their headaches usually last fewer than 30 minutes, dissipating once they get out of bed and start their morning routine. These headaches are usually low grade and are not debilitating.
Comparatively, patients with migraines report longer-lasting, more severe headaches. These also, along with cluster headaches, can be triggered by the hypoxemia and hypercapnia that occurs from obstructed airways during sleep.
As always, consider brain tumors, ruptured aneurysm, stroke, severe hypertension, alcohol intoxication, sinus infection and muscle-contractions as differential diagnoses for any headache disorder.
There are also several other sleep disorders that may cause headaches. These include bruxism, parasomnias, insomnia, REM sleep disorders and sleep-phase related disorders. Bruxism is a common sleep disorder in which the headache pain is a result of an increase in temporomandibular joint stress and muscle contraction.
In any case, if the patient is waking with headaches order a polysomnogram to evaluate for OSA and other sleep disorders. When migraine headaches are not controlled well with medication, you should entertain the possibility of a comorbid sleep disorder.
Migraine sufferers should always be advised to practice good sleep hygiene, as it will improve the frequency and duration of their headaches.2 Keeping a regular bedtime schedule is important. Migraine headaches occur more often during REM sleep, so avoid the urge to sleep late which promotes REM sleep. Other migraine triggers during sleep include sleep deprivation, alcohol, stress and trauma.
Needless to say, starting a day off with a headache is no fun for anyone. If your patient complains of ongoing headaches, especially upon waking from sleep, consider OSA as a possible cause.
Sharon M. O’Brien, MPAS, PA-C, works at Presbyterian Sleep Health in Charlotte, N.C. Her main interest is helping patients understand the importance of sleep hygiene and the impact of sleep on health.
- Smith H, Comella C, Hogl B. Sleep Medicine. New York: Cambridge University Press. 2008. pg 165-166.
- Principles and Practice of Sleep Medicine. Fourth Edition. Philadelphia: Elsevier Saunders, 2005. pg 879-888.