Discussing a Connection Between Sleep Disorders and Headache

In part 2 of this video,  Karl Doghramji, MD, director, Sleep Disorder Center, professor of psychiatry, Thomas Jefferson University, interviews Stephen Silberstein, MD, professor of neurology and director of the Jefferson Headache Center, Thomas Jefferson University, Philadelphia, Pennsylvania on the connection between sleep and disorders such as headaches, anxiety, and depression.

In the previous part 1, Dr Dogharamii and Dr Silberstein discussed the importance of sleep in the production of body homeostasis and the glymphatic systems ability to drain buildup of toxins in the brain.

Read the Transcript:

Dr Doghramji: Steve, what is the role in the glymphatic system and its connection with sleep in the role of generation of headaches?

Dr Silberstein: If you create toxins that are in the brain, you'll produce fogginess, and you can also make headaches worse. You don't sleep, and your poor sleep is one of the things that trigger headaches. It's the relieving factor.

Think about it. We tend to think of migraine as due to the presence of neuropeptides, CGRP, VIP, PACAP, and other chemicals. If they accumulate in the substance of the brain and they're not washed out, it's quite conceivable that they could continue to act and not get washed out.

Also, delirium, you may or may not realize that people in the emergency room in the hospitals and ICUs get delirium. People use a norepinephrine antagonist to stop the delirium because it opens up the pathway.

Dr Doghramji: We do have data, don't we, that improved sleep and headache patients can benefit them in terms of headache. Do we not have those data?

Dr Silberstein: As you are well aware, all of my patients with chronic intractable headache are sent to you. I honestly believe it, and we have data to show that one of the risk factors for aggravating headache is sleep disturbances. I can tell you, we've gotten as many patients better by you picking up obstructive sleep apnea than anything else.

Migraine is not caused by a sleep disturbance, but it's aggravated by it. So, if the systems aren't working, it acts as a balance, and the balance is tipped toward headache.

I think you need to take sleep disorders into account. Sleep disorders can produce migraine, migraine produce the sleep, and primary sleep disorders can aggravate migraine, is the way I tend to look at it.

Dr Doghramji: That rings so true to a sleep specialist such as myself. We see headaches, some migrainous in nature, in patients with various sleep disorders, including narcolepsy, as you mentioned, sleep apnea, but also things like circadian disruption, a delayed sleep phase, shift work disorder, and even insomnia in general.

All of these folks wake up in the morning and have this headache, sometimes big and sometimes migrainous in nature. Often, helping them with their sleep disorder is beneficial for the headache itself.

These are important messages to all of us clinicians. Not only neurologists, psychiatrists, but also sleep specialists to be watchful for the connection between sleep disturbances and headache.

Alzheimer disease, you mentioned, the proteins that build up in Alzheimer disease, the amyloid beta, tau proteins. These are not excreted as robustly in patients with glymphatic system abnormalities. We know that patients who have poor sleep over the long-term may develop cognitive abnormalities.

I'm wondering whether one of the ways in which we may be able to help our Alzheimer and demented patients is to be able to help them with sleep. What are your thoughts?

Dr Silberstein: I agree 100 percent. We know that delirium has helped. Why not look at some of the drugs that they use in the ICU. I think it's dexmedetomidine. Forgive me, if I'm incorrect. Why not try drugs like that in people who have difficulty sleeping and wake up foggy and see what happens?

Basically, it's a noradrenergic antagonist, and there are a lot of them around. Why not look at drugs like that in people who have fogginess in the morning to help them get through the night?

Dr Doghramji: We've touched on a very important topic. It's safe to say that there'll be more research done in this area in possibly developing new therapeutics, which can actually impact the glymphatic system itself, which may be able to help in a wide variety of disturbances of sleep and comorbidities, such as headache, the mental disturbances, anxiety, depression.

Even depression, we haven't spoken about this very much, but it's interesting that long-term sleep disturbances are a very strong premonitory difficulty when it comes to the production of depressive disorders, not just feeling depressed but major depression, which is highlighted by difficulty with sleep.

Difficulty with sleep is really a premonitor or heralds, the development of, major depression in so many different patients. Possibly, helping these folks in advance of the development of depression with sleep can actually avert the development of major depression, and maybe glymphatics are the connection that we've been looking for.

Dr Silberstein: I would add one thing we didn't talk about. We've talked about bulk flow of the spinal fluid from the CSF into the interstitial spaces, but something else is new.

We now know that spinal fluid isn't stationary. There's evidence now in humans, by MRI imaging, that spinal fluid continues to move bulk flow, up and down. You have this bulk flow of external spinal fluid which is then mixing with the spinal fluid that's in the extracellular space.

The other thing that's recently been discovered is that all of the spinal fluid, it's not generated in the choroid plexus but actually comes out from the brain itself. It's a much more dynamic system than we thought about before.

Perhaps, if you think about it, people with Chiari malformations, why do they get some of the symptoms? Maybe it's preventing the bulk flow of spinal fluid up and down. It's really interesting, really new, and really exciting.

Dr Doghramji: This is absolutely fascinating, so many different avenues to think about as we think about this glymphatic system. I'd like to thank you, Dr Silberstein, for this fascinating interview. I'd like to thank all of you for joining us today on the Psych Congress Network.

Karl Doghramji, MD is Professor of Psychiatry, Neurology, and Medicine at Sidney Kimmel Medical College of Thomas Jefferson University in Philadelphia, Pennsylvania, and Medical Director of the Jefferson Sleep Disorders Center at Thomas Jefferson University Hospital, also in Philadelphia. Dr Doghramji is also Program Director of the Fellowship in Sleep Medicine.