S4:Ep2 – The Relationship Between Migraine and Sleep


Voice-over: Welcome to Spotlight on Migraine, hosted by the Association of Migraine Disorders. Join us for fresh perspectives by medical experts and advocates as we explore the spectrum of migraine and dig deeper into this complex disease.

This episode is brought to you by our generous sponsor, Impel NeuroPharma. 

Managing a healthy sleep schedule can be difficult. Adding a chronic pain condition makes it that much harder. Stay tuned as Dr. Steven Bender explains sleep disruptions, the impact sleep can have on migraine, and strategies for improving this relationship.

Molly O’Brien: Hello, and welcome to Spotlight on Migraine. I’m your host, Molly O’Brien. Migraine and sleep and pain have an interesting connection. Many of those living with migraine have a complicated relationship with sleep. So we’re going to talk a little bit more about that, what the relationship is, and hopefully some ideas on how we can improve our sleep and begin to feel better.

I’d like to introduce our guest today, Dr. Steven Bender. Dr. Bender is the director of Facial Pain and Sleep Medicine for the department of Oral and Maxillofacial Surgery at Texas A&M College of Dentistry. Dr. Bender, thanks so much for joining us today.

Dr. Steven Bender: Well, thank you, Molly. Thanks again for having me.

Molly: Well, we had a great conversation last time all about TMD, and I know that helped a lot of people out. So we’re going to dive into another area of your specialty. Let’s start off kind of basic. Like I said before, a lot of people with migraine have a complicated relationship with sleep. Can you just tell us a little bit about how sleep and pain are tied together?

Dr. Bender: Certainly, and it’s kind of, as you mentioned, a complex relationship. For years and years and years, we considered it to be a bidirectional relationship. By that, I mean you consider somebody with a pain condition such as migraine, maybe, that interferes with their sleep. And then, in turn, the person has poor sleep because of this pain, and that doesn’t allow the body to heal or recover or respond the way it should.

I think now it’s probably more accepted that it’s not as bidirectional as we thought it would be, that a number of studies have shown us that a period of poor sleep actually can predict the onset of new pains more so than the pain can predict onset of poor sleep. So, again, the relationship is somewhat vague, but we know that they’re involved in a very intimate fashion. And, ultimately, many of us that have migraine know that sleep can either be a blessing or a curse.

Molly: So there are things called sleep disorders, like sleep apnea, insomnia. From what you know, have you seen that people with migraine are more prone to sleep disorders or are more people with sleep disorders prone to migraine?

Dr. Bender: So, yes, I would say that people with migraine tend to be more prone to sleep disorders. And there are studies that actually have looked at that, where a person with normal sleep for forever, and let’s say they start having more and more migraine, well, we can almost predict that they will begin to have insomnia, which is the inability to either fall asleep normally or stay asleep normally or sleep for an adequate period of time. 

So there’s that, but then there’s also sleep disorders like sleep apnea, where we stop breathing during sleep, or other — like snoring or flow limitation, which is where we don’t snore, we don’t stop breathing, we just have this increased effort to breathe because the airway’s getting smaller. So these disturbances during sleep interrupt normal sleep, and we know that normal, good sleep is important especially for those of us that have migraine. 

I’m sure everybody’s heard of the neurochemical serotonin. I mean, it’s kind of like one of those feel-good chemicals in our brain, in our body. And we know that normal secretion is important, and we also know now that people with disturbed rapid-eye-movement sleeps tend to have a dysfunction in the production of serotonin.

So if our sleep is disturbed and we’re not getting adequate rapid-eye-movement sleep, we’re going to be more prone to pain conditions because that serotonin, besides making us feel good, actually in our brain kind of filters out the pain signals that go up there to get processed. And so without that adequate filter — we call it the descending inhibitory system, which just means the brain is trying to keep the pain down. Without adequate serotonin, we’re going to be more prone to have more pain and headache and mood disorders.

Molly: And then that also connects with mood as well, which is so interesting.

Let’s talk a little bit more about quality of sleep and lack of sleep. Can poor sleep or lack sleep actually decrease our tolerance of pain? You kind of touched on this when you were talking about serotonin.

Dr. Bender: Yeah, and there’s been a number of studies too that have looked at artificially interrupting sleep. It seems to decrease our pain threshold, and so we’re just more sensitive to pain. What’s really interesting, too little sleep or too long of sleep — which we used to think, “Well, the more sleep, the better.” If we sleep too little or too long, we are also more prone to pain conditions too. And, again, it has to do with interrupting the normal circadian cycles that are important not just for sleep, but for pain conditions as well.

Molly: So, I mean, that makes sense, then. Doctors tell us — those of us living with migraine — you want to keep a consistent schedule: try to go to sleep at the same time, try to wake up at the same time. So that makes sense. 

A lot of us think lack of sleep, so that can decrease our tolerance for pain, trigger migraine, we feel like garbage. But also, on the flip side, you just want to sleep in on Saturday or Sunday morning, and that can also put you in the wrong state. So having that routine, it all makes sense.

Dr. Bender: Yeah. And when we look at the timing of headaches too, especially related to sleep, and it tends to be very circadian related and also sleep stage related. In other words, for example, a lot of people will tend to have more headaches either during or awakening during the REM sleep period. And if we think about the distribution of sleep cycles, the first part of our sleep during the sleep period is going to be deep sleep, so we get a lot of stage 3 sleep, very little REM sleep, whereas early morning hours tend to be more REM sleep. And that’s why a lot of people, early morning hours, have vivid dreams or they wake up and remember their dreams, because those happened in REM sleep. 

Well, also we’re more prone to headaches during the REM period or awakening from REM sleep, and so if we’re sleeping longer and longer and longer in the morning hours, we’re having more REM sleep. And too much of a good thing can cause us to wake up with headaches.

Molly: Yeah, that’s so interesting. And we actually had a viewer question, so maybe you can just kind of double down on that information. One of our viewers wanted to know why they usually wake up with a headache or — and I’m sure there’s a lot of different answers for that. They could have TMD, and they’re clenching down, or there could be a lot of issues. Your neck’s not right on your pillow. But that’s really interesting. Do we see a lot of people have that issue, waking up with headache?

Dr. Bender: Yeah, I think, again, a lot of people will either wake up during sleep with a headache — and there’s some particular headaches that are not migraine that awaken us from sleep, and we call those hypnic headaches because it’s usually about the same time. But even with migraine, people will wake up based on their circadian or sleep stages, and then even more people tend to wake up in the morning with headache due to that. 

Now, that can also be sleep breathing related too. There’s a number of people that wake up in the morning with a pretty significant headache, and I — this was one of my presentations — just not breathing good during sleep can not only disrupt sleep, but the lack of oxygen. And then we wake up, and we have a bad headache.

Molly: I think it’s fascinating that there could be different answers, but it sounds like if that’s something that’s going on with one of our viewers at home, that seeing a sleep specialist might actually benefit them, just to see if that’s what’s going on with them. Is that fair?

Dr. Bender: Yes, absolutely. I encourage a large amount of our patients that I suspect sleep disorders to get a sleep study, those that have refractory migraine, especially. They’ve seen number of specialists, they’ve tried a number of preventives and abortives, and they’re still having a lot of problems. We try to explore their sleep as much as possible because that could be a big component. 

And not just sleep breathing issues — other sleep disorders too can certainly interrupt proper sleep. And you mentioned it: the routine of going to bed at the same time, waking up at the same time, even on weekends, which we don’t like to do. But it’s so important that we maintain what we call that homeostatic process, because basically, migraine patients, our homeostasis is messed up anyway, and so the more we can try to correct that, the better.

Molly: More routine, the better, which isn’t always easy to accomplish.

Bender, I want to talk to you about an article you wrote. I thought this was really awesome. In this article, you wrote about the snooze button, which — I feel like there’s two kinds of people. There’s people that will snooze and snooze and snooze and the people that just hop out of bed. I am not one of those hop-out-of-bed people. But what you wrote in that article, it has inspired me to try to be one of those people. How a lot of us feel like, oh, 5 more minutes, 10 more minutes in bed will make a difference — I’m tired. I don’t feel well. Just give me a couple more minutes. You ask your mom when you’re a kid, “Five more minutes?” 

But hitting snooze could actually be harmful for us. Can you talk a little bit about just why that is and then if there’s anything else we can do to kind of get ourselves up and going in the morning rather than just hit snooze a hundred times.

Dr. Bender: So I’m kind of chuckling inside with that particular piece I wrote just because of some of the extreme feedback that I did get, people —

Molly: Oh, I bet.

Dr. Bender: — telling me they’re snoozers and I’m crazy and they’re going to continue to snooze away. That’s fine.

Molly: It’s your life.

Dr. Bender: Yeah. And for some people, that’s fine. To me, it’s like, OK, what difference is 5 minutes going to make? What difference is 10 minutes? So I’m one of those people, actually, that’s got a built-in alarm, and I just wake up before my alarm. 

But hitting the snooze button, especially hitting it repetitively — as I said, the early morning hours are more rapid-eye-movement sleep. And so we keep throwing more and more of this stage of sleep into a bucket, if you will, that’s already full. And the more we put in this extra non-purposeful sleep, the worse it’s going to affect the mechanisms that are involved in headaches. So we’re just going to be more prone to headache, to just feeling yucky, not waking up refreshed. 

We call it sleep inertia, which basically means we wake up and for a period of time, we can’t focus. We don’t feel good. We’re grumpy. We don’t want to talk to people. Well, the more we push that snooze button, the more sleep inertia we’re developing. 

It’s kind of like people taking naps that are too long. A good 30-minute nap is fine, but if you start incorporating more and more sleep cycles, which are 60 to 90 minutes each, and we start piling those up, the more prone we are to sleep inertia, but also waking up from a nap with a headache.

Molly: That is absolutely fascinating, and, again, it seems to make sense. Now, do you have any advice on how to practice doing this? If you’ve been in a bad habit, maybe your whole entire life, of hitting that snooze button, any expert advice on that? Just get up and deal with it?

Dr. Bender: And you’re asking for a friend, I know —

Molly: Of course, yes, 100 percent.

Dr. Bender: — not for yourself.

Molly: All the friends watching.

Dr. Bender: That’s right. It’s like we hear — those of us with migraine, we hear this about everything. We just have to become more disciplined with certain aspects of our life — what we eat, how we hydrate, exercise — and sleep is really important. So we try to establish more normal sleep schedules, where we go to bed approximately at the same time, we wake up at the same time. Before bed, we try to do the things that are going to be conducive to sleep, like going into a quiet environment, a dark environment, putting our devices away, not eating or drinking for at least about three hours before bedtime, because that’s going to interfere with urine production and things like that, so it’s going to awaken us to have to go to the restroom.

So, good sleep hygiene, good sleep timing, and then just trying to stick with that even on the weekends, waking up at about the same time that you do normally, or at least awakening and then getting right up instead of forcing yourself back to sleep, if you will, saying, “Today I’m going to sleep till noon.” Well, maybe you don’t need to do that.

So it’s one of those discipline things, and, like in my case, you just have enough of waking up every day with a headache, and finally you say, “OK, I need to do something about this loud snoring” or trying to sleep in, that kind of thing.

Molly: And I think you hit the nail on the head, right, that those of us living with migraine have to make certain changes. And if it’s something — it’s hard, not hitting the snooze button, but a lifestyle change that could make a big difference, it’s definitely worth trying. So it’s always good to hear about options, and we can always get better at sleep, I think.

Dr. Bender: Yeah. I heard a wonderful quote from a clinical psychologist not too long ago, and he said, “Everybody wants to grow, but no one wants to change.”

Molly: That’s very true.

Dr. Bender: And so to grow, we have to change and we have to change what we’re doing, because what we’re doing has not really been effective. At least, in my case, it wasn’t. And so if I wanted to start feeling better, have fewer headaches, then I knew I had to do certain things to accomplish that.

Molly: Well, good for you, and hopefully we can get some help for some folks out there as well. I’ll be right there with you folks that don’t do well with the snooze thing. I’ll be right there with you. 

And I really like that quote. 

We have some questions from our followers, if we can get to those. This person wants to know — they say, “Many of us wake up due to head, neck, shoulder, or lower-back pain,” and they want to know if there’s any tips on how they can avoid reducing waking up with this kind of pain. So that pain might contribute to migraine, or it also might just be they have chronic pain issues or pain with sleeping.

Dr. Bender: So there could be multiple factors, like you said, on why. One could just be your bed. If we don’t have a good bed, a good pillow, we are going to be uncomfortable. And, again, this is something that I’ve experienced in my lifetime. You don’t think, “OK, I really need to change this bed.” It’s just you sleep in it, and you just keep sleeping in it. And then exploring multiple different pillows until somebody said, “Why don’t you get fit for a pillow?” And I thought, “Wow, what a concept.” So just the bed that you’re sleeping in, the pillow that you’re using are super important.

Sleep position is really important too. We know that a lot of us want to sleep on our stomach, or I used to, and sleeping on your stomach is bad for a lot of reasons. But, number one, we’re turning our head. We’re not breathing good because the pillow’s there. We’re causing excessive movement in our neck. Jaw muscles too are not happy with that. And we know that the little filtering mechanism that happens in our brain — we call it the glymphatic system, kind of like the lymph system — it doesn’t really work with sleeping on our stomach. And so we’re not filtering all the bad stuff that we accumulate through the day.

We need a good sleep temperature, just to avoid restlessness, which may induce other body pains. We need to have a cooler bedroom environment. Some would say 64 to 67 degrees is ideal. So, that. Other interruptions, like light. People sometimes want to keep the TV on. Some people want to have music playing. So part of good sleep hygiene is that, and if we have good sleep hygiene, we’re less prone to be moving around in awkward positions that may cause other body pains.

And I guess the bottom line is if there are significant other pains, then you need to consult a professional, possibly some kind of physical therapy or other interventions to eliminate those, because they can interfere with good sleep.

Molly: And it all sounds like great strategies there, dealing with a bed and a pillow and sleep position and keeping it cool and dark — again, all things that we can work towards making just simple changes at a time. 

I’m curious, if someone’s interested in getting fitted for a sleep pillow, how would you even get started on that? I know that pillows are a thing in our house. We have about every pillow under the sun. So if someone’s interested and saying, “Hey, you know what, my neck hurts, I’m kind of off,” how do you get started on getting fitted for a pillow?

Dr. Bender: Well, it’s not easy, because I’ve gone through many over the years. And what I found is the better sleep stores, so the better sleep beds, will often have pillows too, and in some of those, there are really educated people helping you buy. And so they’ll ask you to lay down. And, like in my case, the pillow I thought I needed was not it. 

And so they had me pick a bed in their store, similar to mine, and then they picked out a pillow, and they just looked: am I kind of straight, or is my head going down into the pillow? Is the pillow wrapping up around my face? And so just finding a good bed store that sells pillows with some knowledgeable people that can actually lay you down on the bed that is similar to yours and just see, does that fit you? Is your spine neutral? Can you breathe well? Does it feel comfortable? So those are some things to look at. 

And, again, not endorsing any particular product, but I find that the natural latex pillows seem to be the best for most people because they’re nonallergenic. They seem to hold their shape as well. They don’t absorb as much sweat and things like that. So the more natural latex-type pillows seem to be the best for most individuals.

Molly: And that’s a good place to start, because the world of bed shopping and pillow shopping can be very overwhelming. There’s a lot of options out there.

Dr. Bender: Yeah, yeah, yeah. And, unfortunately, some people can just go to the big box stores and grab a mattress and they’re good. But people like me, especially as I get older, it takes a little work to find something that doesn’t make the back hurt or the knees hurt or things like that.

Molly: I’m right there with you. I’m right there with you. Some fascinating information. I hope this has been helpful to you watching and listening at home. I’d like to thank our guest, Dr. Steven Bender, for joining us today. Dr. Bender, thanks again.

Dr. Bender: Thank you, Molly. It’s always a joy and a privilege, actually, to speak to the audience.

Molly: Thank you. It’s a privilege as well to have you.

All right, well, everyone, thanks so much for watching. Hopefully, you can use some of the information you learn here to get a better night’s sleep and start feeling better. My name is Molly O’Brien, with the Association of Migraine Disorders, and we’ll see you next time.


Voice-over: Thank you for tuning in to Spotlight on Migraine. For more information on migraine disease, please visit MigraineDisorders.org.

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