Episode 17: Headache and Sleep
Headache is a common symptom in people with sleep disorders. Headache can also cause sleep problems. We discuss the link between headache and sleep, as well as some simple sleep strategies to improve both headache and sleep. In this episode we are joined by expert neurologists, Dr Andrew Evans and Dr Anne Calhoun.
Dr Moira Junge (Health Psychologist) and Dr David Cunnington (Sleep Physician) host the monthly podcast, Sleep Talk, talking all things sleep.
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Audio Timeline:
- 00:00 – 00:52 Introduction
- 00:52 – 07:43 What’s news in sleep?
- 00:52 – 02:33 World Sleep Day
- 02:33 – 6:30 Daylight Saving Time
- 06:30 – 31:37 Theme – Headache
- 06:30 – 09:40 Background – Headache and Sleep
- 09:40 – 18:00 Guest interview – Andrew Evans
- Headache syndromes
- Who should be sent to a neurologist?
- Hyper-mobility syndromes and headache
- How are headaches treated?
- 18:00 – 31:04 Guest interview – Anne Calhoun
- Link between headache and sleep
- Reducing headache by improving sleep
- 31:04 – 34:05 Summary – Headache and Sleep
- 33:37 – 32:37 Clinical tip of the month – Simple things can give big results
- 32:37 – 35:55 Pick of the month:
- 32:37 – 33:40 Moira – A Mindful Way – online mindfulness course for insomnia
- 33:40 – 35:55 David – Sleep – Book of quotes on sleep
- 35:55 – 38:22 What’s coming up in sleep?
Next episode: May 1st – Mindfulness and Sleep
Links mentioned in the podcast:
- World Sleep Day
- World Sleep Day – Sleep Health Foundation challenge
- Busting Sleep Myths – Today show
- 2GB radio interview – Moira
- Daylight Saving Time panel – Sunrise
- Richmond Neurology – Dr Andrew Evan’s clinical practice
- Caroline Headache Institute – Dr Anne Calhoun’s clinical practice
- Sleep symptoms in people with headache – Headache Journal 2006
- Managing sleep to improve headache – Headache Journal 2007
- Headache Australia
- Sleep and Headache Disorders – review in Headache Journal
- A Mindful Way – online mindfulness course for insomnia
- Sleep 2017 meeting – Boston June 3-7
- World Sleep Congress 2017 – Prague October 7-11
- Sleep Down Under 2017 meeting – Auckland Oct 27-29
- Mindful in May
Presenters:
Guest interview:
Dr Andrew Evans trained at the Royal Melbourne, Western Hospitals and the Kingston Centre. He spent over 4 years in a movement disorders fellowship at the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK. Dr Evans is the current director of the Movement Disorders Service at the Royal Melbourne Hospital. He has published extensively on the disease particularly addressing symptoms that impact on the quality of life of sufferers and heads a number of clinical research trials. In addition to his research, he is also a member of the Melbourne Health Ethics Committee. Dr Evans’ private practice is at Richmond Neurology.
Dr Anne Calhoun is a graduate of the University of Tennessee College of Medicine. She completed her internship and residency at the University of Tennessee/Baptist Memorial Hospital. Dr. Calhoun is Board Certified in Internal Medicine, Headache Medicine, and Menopause. Her interests include women’s issues in headache, menstrual migraine, and sleep disorders in headache. Dr Calhoun has published on sleep in people with migraine and the impact of improving sleep on headaches. and practices at the Carolina Headache Institute in Durham, North Carolina.
Regular hosts:
Dr Moira Junge is a health psychologist working in the sleep field, who has considerable experience working with people with sleeping difficulties in a multidisciplinary practice using a team-based approach. Moira has consulted at Melbourne Sleep Disorders Centre since 2008, and is actively involved with the Australasian Sleep Association (ASA). She has presented numerous workshops for psychologists wanting to learn more about sleep disorders, and is involved with Monash University with teaching and supervision commitments, as well as clinical involvement with the Monash University Healthy Sleep Clinic. She is one of the clinic directors at Yarraville Health Group which was established in 1998. In addition to her expertise in sleep disorders, her other areas of interest and expertise include smoking cessation, psychological adjustment to chronic illness, and grief and loss issues.
Dr David Cunnington is a sleep physician and director of Melbourne Sleep Disorders Centre, and co-founder and contributor to SleepHub. David trained in sleep medicine both in Australia and in the United States, at Harvard Medical School, and is certified as both an International Sleep Medicine Specialist and International Behavioural Sleep Medicine Specialist. David’s clinical practice covers all areas of sleep medicine and he is actively involved in training health professionals in sleep. David is a regular media commentator on sleep, both in traditional media and social media, and blogs for the Huffington Post on sleep. David’s recent research has been in the area of non-drug, psychologically-based treatments such as cognitive behavioral therapy and mindfulness in managing insomnia, restless legs syndrome and other sleep disorders.
Connect with David on Twitter or Facebook.
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Transcript:
Welcome to Sleep Talk, the podcast about all things sleep, brought to you by SleepHub.com.au. Here are your hosts, Dr. David Cunnington and Dr. Moira Junge.
Dr. David Cunnington: So welcome to episode 17 of Sleep Talk and welcome Moira.
Dr. Moira Junge: Hello Dave. Hello everyone.
Dr. David Cunnington: So the theme of this episode is headaches and how do headaches and sleep go together. Well, it turns out someone on Facebook contacted me and said, look, you should do a podcast about headaches and sleep. I thought, “Yeah. Really?” But ever since then, I’ve been listening to people talk about their sleep and lots of people have headaches.
Dr. Moira Junge: Yeah, and can’t sleep as well.
Dr. David Cunnington: Yeah. These two things really do seem to go together. So it’s a good topic and that’s what we’re going to talk about is how do headaches and sleep relate to each other and how do they impact our nature. So what has been going on for Moira?
Dr. Moira Junge: Well, I had a big month. It was World Sleep Day of course on March 17th, which clashed with a few other things on St. Patrick’s Day and Ride to School Day and there’s a few other – we’re competing with a few events on that Friday the 17th.
Dr. David Cunnington: There are so many days. Everything is stacking up, isn’t it?
Dr. Moira Junge: I know. So we did have – we tried to have a bit of a thing, a call to action rather than just a day. But you didn’t get a little leverage.
Dr. David Cunnington: We tried though. You were in the media. I saw you promoting it and I’ve tried to give it a plug in today’s show.
Dr. Moira Junge: Yeah, yeah, yeah. I know. I think there’s a bit of fatigue around World such and such day.
Dr. David Cunnington: Yeah, true.
Dr. Moira Junge: Don’t you think?
Dr. David Cunnington: Yeah, I had a great …
Dr. Moira Junge: Yeah.
Dr. David Cunnington: I really like the thing that you’ve chosen. I reckon that’s really relevant in this day and age if you take an hour off the screens and set aside an hour more for something else or an hour more for sleep.
Dr. Moira Junge: Yeah. I think we will try again with that. But maybe not even on World Sleep Day. Maybe in some other capacity, some other time, because all of us need to take that call to action. There were a couple of people that we’re really interested in. I shouldn’t say there was no media interest. I did a very lengthy radio interview. There’s like a – a guy Ray Hadley I think or something like that who’s very well-known. I shouldn’t be saying something like that. I knew who he was.
He was great. We had a great discussion around it all and he was particularly interested in that. But funny enough, the interview was quite late at night. It was quite ironic. He didn’t get my number right. I thought, well, it must be not on. He will ring at the appropriate time and he rang at 10 o’clock at night, on the night we were meant to turn our screens and everything off. I was in bed.
Dr. David Cunnington: You’re following your exam.
Dr. Moira Junge: Yeah. So we had a bit of laugh about that.
Dr. David Cunnington: And then you were also on the TV talking about Daylight Savings. We’ve been through that shift. I saw you on television talking about that. What happened with that?
Dr. Moira Junge: Yes. So me who hates television. I said never go on it again. I got a good face for radio. I went back. Because it was a Daylight Savings panel, I said let’s – can you have it come on and – they wanted someone from the Sleep Health Foundation. Everyone else stood back and I was left standing. I tried to get – I said OK, I will do it. It was a panel. It was sort of two guys, one in Perth and one in Cairns and me. You know, panel screens on the TV screen. It was meant to be a debate and a discussion around Daylight Savings pros and cons and then the – as the health expert about what sleep is all about in terms of losing an hour of sleep and then potential dangers.
So of course, there was no debate. It was not really a big discussion. I had about 30 seconds of wisdom. But it’s good. At least I didn’t – it was fine. But it was interesting because I was saying, you know, Daylight Savings at one hour is a spike in crashes and strokes and heart attacks and judges being harsh with their sentencing. I thought, “Wow!” because I saw the research.
Dr. Moira Junge: Oh, did you? And then they said they made a lot of – well, I was nervous, like waiting for me to come on there, how we’re showing all their footage. Like, they had a little story about it all and it started with the hammer going bang. I thought, no, my heart is pounding, going on a Saturday morning. But my take was that – one hour – well the research, I looked at the fine print of the research and the spikes say it’s 20 percent increase. At the end of the daylight savingwe get an hour more, the spike is reversed. He would get 20 percent decrease in those things.
So it sort of evens itself out over the time. I had a discussion with some colleagues before I went to – I was representing the Sleep Health Foundation. Well, it’s not just my opinion. What’s our party line on Daylight Savings? Health effects, is it good or bad?
The consensus is well, in general terms, that one hour we lose – in a few days or so, you adapt. You adjust to that. We all know how to adjust that as mammal. It’s not that dangerous. I don’t think it’s a general thing. Otherwise, none of us would be flying anyway. Like one-hour difference, we’re going to crash our car the next day. It’s not a general thing we do. But in general terms, if we’re manipulating light or manipulating the time to have more light, in general, but more light is better for your health.
Dr. David Cunnington: Yeah.
Dr. Moira Junge: So that was my party line. That’s what I spoke about and I think that’s why we kind of just fizzed out with the debate. There was no kind of – oh, right? OK, thanks Moira. Thanks everyone. Then we went to the end break. Anyway …
Dr. David Cunnington: Well, I don’t like that way of thinking about it too that there’s – sure, you get a bit of circadian misalignment for a day or maybe short term sleep loss. But the game is more physical engagement with the outside world and …
Dr. Moira Junge: Yeah, and I understand those places. It was interesting. It was Perth and Cairns that these guys were talking about and Western Australia and Queensland don’t have Daylight Savings. But they have a different climate to us and it’s very, very hot and it gets light. So they can [Indiscernible] most of their mornings a lot more than we do in the Southern and Eastern states. Maybe they just don’t need Daylight Savings and I think it’s really beneficial overall for us.
Dr. David Cunnington: Yeah.
Dr. Moira Junge: I would say thought just the last two weeks or so – I think it should finish early March because it’s very dark and …
Dr. David Cunnington: It a bit draining on …
Dr. Moira Junge: It’s a bit long. So that’s one thing I would probably – next year, I would go in this program and debate. I just think the end of – by the end of summer, end of summer, end of February, start of March, that would be better because I think it’s really like winter in the morning. So it’s a quarter past 7:00. It’s quite dark.
Dr. David Cunnington: Yeah.
Dr. Moira Junge: It’s a hot day. It’s really weird.
Dr. David Cunnington: Yes. It has been a bit strange in the last couple of …
Dr. Moira Junge: Yeah. But I’m happy to – I just recently got the extra hour. You can’t complain with that. That was good.
The theme to this month’s podcast is headaches and how do headaches interact with sleep. Do people with sleep disorders get headaches more commonly than people otherwise? Would headaches conversely impact on sleep? That was an introduction. This was a topic that was really highlighted to me by someone who sent me a message on Facebook. So nice example. If you want us to do a podcast and research this particular, send us a message and we will look into it for you.
So as doing some of that background research, that’s how we’ve come up with the guests that we’re going to speak to in this episode. Andrew Evans, who’s a colleague of mine, a neurologist here in Melbourne and Professor Anne Calhoun from North Carolina.
When I started looking into this and listening to people talk about sleep and in particular having my sort of ears pricked listening for headaches, I did seem to find lots of people have headaches and different types of headaches – migraine headaches, what we think of more as tension type headaches, persistent headaches, cluster headaches and there’s even a condition called Exploding Head Syndrome, which is a sleep disorder where people get a sudden headaches on going off to sleep.
So it really has opened my eyes to the fact that headaches and sleep problems do seem to go together. But what about you, Moira? What are you seeing with people you work with?
Dr. Moira Junge: I haven’t really thought about it that much. A lot of people, a lot of women particularly report headaches and linking with their menstrual cycle and dehydration as well.
Dr. David Cunnington: Yeah.
Dr. Moira Junge: I just think about whether their headaches are causing the sleep disturbance or whether the sleep disturbance is causing the headaches. Obviously it’s a bit of both. What’s your general feeling about what comes first – the chicken or the egg?
Dr. David Cunnington: I’m sure there will be each – examples of each, so examples where people get say a headache syndrome with migraine and it really is painful and disturbs their sleep and then also we know if people aren’t sleeping well. Just say they’ve got insomnia or they’re waking a lot during the night.
The way the brain blood flow operates is different. So you don’t get the same reduction in brain metabolic activity and therefore the same reductions in brain blood flow. So that sets you up to get a vascular mismatch in terms of blood flow and how much you need, which is the right ingredients that you get a migraine.
Dr. Moira Junge: Yes.
Dr. David Cunnington: I think of that too in circadian rhythm disorders where if you’ve got a delayed phase or your body is not expecting to be up, it’s expecting to be laying in bed, but you’ve set the alarm and you’re up early and you’re upright and getting to work. Your brain blood flow isn’t going to be regulated in the same way. It’s going to be regulated as if you should be lying flat. But you’re actually standing up.
Dr. Moira Junge: Yes.
Dr. David Cunnington: Which is the right ingredient as well to get a headache and the problem with the brain.
Dr. Moira Junge: To feel out of sorts.
Dr. David Cunnington: Yeah.
Dr. Moira Junge: The other factor too I guess with headache and other parts of chronic pain is that sometimes people really have to take the day off work or they withdraw into bed and then they sleep the day away. So then it just becomes problematic with that night-time sleep because they’ve had to kind of just retreat and get some sleep. But sometimes people just say I just need to go to bed. I just need to get in a dark room and just sleep it off.
Naturally as we know, if it’s a big, long, chunky sleep, it does interfere with the night-time sleep period. So yeah, so I think it’s great. I’m glad we’re discussing it. It’s something that a lot of people – it’s very, very common.
Dr. David Cunnington: Yeah.
Dr. Moira Junge: A lot of people suffer with this.
Dr. David Cunnington: So he will give us some background just on headaches themselves and the different types of headache syndromes and common headache treatments. I had the chance to talk to Dr. Andrew Evans. So Andrew Evans trained in Australia but also spent four years training in the UK at Queens Square and he’s currently the Director of the Movement Disorders Service at The Royal Melbourne Hospital. But in his private practice and a lot of his practice actually, has a particular interest in headaches. So thanks for joining us, Andrew.
Dr. Andrew Evans: Thank you very much, David.
Dr. David Cunnington: There’s a range of different headache syndromes. Some people I see who have trouble with sleeping describe different types of headaches. What are the different headache syndromes?
Dr. Andrew Evans: Headaches are incredibly common in the community. About 15 percent of people experience some sort of headache. Probably the commonest type of headache syndrome is migraine and this is much more common in females compared to men. The other types of headache syndromes that can be quite common include chronic tension headache and then there are more uncommon types of headaches that have a particular relevance to sleep, cluster type headaches.
Dr. David Cunnington: Of people I’m seeing with sleep problems, who do you recognise should be sending along if they’re reporting headaches?
Dr. Andrew Evans: It’s often hard to know whether the sleep disorder causes the headache or the headache causes the sleep disorder. What’s really interesting is for instance with migraines – now these are – this is a disorder that typically comes on in adolescence or 20s and 30s. The migraines are usually associated with headaches, though interestingly not all migraines involve a headache. The headache tends to have at least a couple of the following types of pain characteristics.
It’s unilateral, pulsating. It’s of a moderate or severe intensity and aggravated by routine physical activity. These sorts of things are quite typical features. In addition, they’re often associated with nausea, vomiting, photo-phobia or phono-phobia. That means sensitivity to light or sensitivity to sound.
When somebody has migraines though, typically you take a pill. The headache goes or have a lie down. But there’s a group of patients who become very debilitated or disabled by virtue of the fact that headaches become very frequent. In people for instance who experience more headache days, not necessarily migraine, but headache days and months and not – these sorts of people are the ones that we should definitely see as part of considering their sleep problems.
Dr. David Cunnington: There’s a subset of people I see with hypermobility syndrome. So problems with collagen or problems with orthostatic intolerance. They seem to get headaches. What sort of headaches do they typically get?
Dr. Andrew Evans: The studies are actually somewhat lacking. But overall, the sorts of headaches you see – typically migraines – are much more prevalent in these individuals. It has something to do with I think hypersensitivity, not just of the autonomic nervous system. This is a nervous system that controls blood vessel tone, sweating and temperature regulation. But also I guess a hypersensitivity perhaps of the pain system as well.
In these sorts of scenarios, then headache situations are very common and they follow a fairly similar routine to the normal types of headache patterns that we see. But I think much more frequently and difficult to treat.
Dr. David Cunnington: Another thing I see with people with sleep problems and headache is teeth grinding. So how does teeth grinding or bruxism, headache, sleep problems, how do they all go together?
Dr. Andrew Evans: This is so under-investigated. We know that teeth grinding in children is very strongly linked to migraines. About 30 to 40 percent of children grind their teeth. In adults, the risk of teeth grinding in general is much less 10 percent. But the impression I have in migraine populations is that, that is much more common and when we’re treating migraines, we – I tend to consider the possibility of teeth grinding. I’m also interested to know whether the teeth grinding can cause arousals in sleep at night-time. That is diminish or reduce your sleep quality and I’m interested when I do treat in terms of how effective that is in terms of reducing that problem.
Dr. David Cunnington: You’ve talked about the headache syndromes. If people have got headaches and thinking about different types of treatment, what are the main types of treatment that are used for headaches?
Dr. Andrew Evans: This is a fantastic question and so important. The first thing to say is that often it’s not about finding the stronger pill or pain reliever. It’s about rational use of these. So we’re very keen on treating headaches early, to get the best effect of the painkilling medications. But not too regularly. So it’s sort of important to withhold those medications when not needed as it is to take them when it is.
So it’s important to have a discussion with your doctor about how frequently you can use analgesic medications, whether it’s even something as simple as Panadol or paracetamol.
The other thing that we look at is preventative medications. Now one of the issues with all of these medications often is tolerability and of course the potential for the medications to have side effects and we often tailor the side effects of these preventive medications to the individual. So if somebody has sleep disturbances, we may be looking at preventive medications that in fact can improve sleep quality.
The last thing that we look at is we look at managing risk factors. Now, everybody is aware or many people are away of triggers. Triggers are things like stress that can suddenly bring on a headache or a migraine headache and trigger avoidance has some role. But when we’re looking at risk factors, these are important aspects of lifestyle that can be modified to reduce the likelihood that you’re going to get a headache next month or after that.
So I’m very big on sleep hygiene, the maintenance of weight, adequate healthy weight, sufficient physical activity and I guess stress management as well and mindfulness techniques and healthy eating.
Dr. David Cunnington: There’s a lot of overlap. We use mindfulness and if I’m seeing someone with non-restorative sleep that’s a bit stress-related and maybe they’ve got some tension headache, I reckon mindfulness is a really good fit for that. There are some people I’ve seen that you’ve managed who have used Botox for headaches. So what’s the role for that?
Dr. Andrew Evans: This has really changed the way that we manage people with headaches and in the past, despite the availability of multiple drugs, they’re really not that effective on the whole and many patients who are having very frequent headaches need some sort of circuit breaker. Botox seems to have a very beneficial effect in the majority of people who are eligible and require it.
When we drip it with Botox, what we’re doing is we’re treating I think the pain fibres as much as perhaps the muscle tension in the head and the neck. Patients tend to get three monthly treatment schedules and the effect tends to build up over time in terms of reducing the number of headaches that you can experience a month.
In addition of course, we can use Botox to treat muscles like the jaw muscles that may be important in terms of teeth grinding or bruxism. So when we treat with Botox, we’re treating the areas that are affected by migraines for head, scalp, temples, back of the head, neck and shoulders, all the areas that are typically affected by migraines.
Dr. David Cunnington: Great. Thanks for those insights.
Dr. Andrew Evans: Thanks very much.
Dr. David Cunnington: So that was really interesting, Andrew’s take on all the different headache syndromes.
Dr. Moira Junge: Gosh, it’s a really special – he has been studying it for such a long time.
Dr. David Cunnington: Yeah. Some of the treatments that he talks about like Botox to relieve that muscle tension in the back of the neck. When you and I work with people say with insomnia or non-restorative sleep, often we’re thinking of muscle tension, that it’s manifesting in a different way, restlessness during the night, grinding teeth, those types of things.
Dr. Moira Junge: Yeah. I think it’s – you sort of just see things with your perspective. I guess what you focus on.
Dr. David Cunnington: So you will like our next guest Moira. So in trying to look at what – how to tie headaches and sleep together, I came across Professor Anne Calhoun from North Carolina.
Around 10 years ago in her role as a headache specialist and the particularly interesting menstrual migraine, she noticed that people she was seeing with migraine had what we would call non-restorative sleep. So they found that yes, they might be sleeping. But sleep is light or not giving them the restoration that they need.
So she did a couple of studies, one looking at characteristics of sleep in people she was seeing with migraine and then a follow-up study seeing if she did something to improve their sleep and you would be pleased, a non-drug strategy and CBT.
Dr. Moira Junge: Yeah.
Dr. David Cunnington: Could she actually make the headaches better?
Dr. Moira Junge: She did.
Dr. David Cunnington: She did.
Dr. Moira Junge: Yeah. Surprise, surprise. That’s great.
Dr. David Cunnington: So Professor Calhoun graduated from the University of Tennessee, College of Medicine, and completed her internship and residency at University of Tennessee in Baptist Memorial Hospital and is board-certified in internal medicine, headache medicine and menopause and has a particular interest in menopausal migraine.
So thanks very much Anne for joining us and helping us out to answer some questions about headache and sleep.
Dr. Anne Calhoun: Happy to be here. Thank you.
Dr. David Cunnington: In my practice as a sleep physician, I do see a lot of people with sleep problems report headache. So what’s the link between headache and sleep?
Dr. Anne Calhoun: Well, it has been reported for quite a while that patients who have chronic migraine or – at least we call them transformed migraines. Have problems with their sleep. So I actually did a study a few years ago looking into just what are all these issues. What I’ve discovered was almost 35 years of doing just headache medicine is that the patient has daily headaches or very, very frequent headaches. They wake up tired. I’ve never seen a patient who has restorative sleep with daily headaches. There’s a very tight connection. So that led me to kind of look to see what are all the issues that we’re dealing with. We found a lot of them.
Dr. David Cunnington: Yeah, that makes sense because a lot of the time, I’m seeing people where they’re coming to me because they’re tired and maybe they’re feeling like they don’t have restorative sleep and headaches come out as part of their symptomatology. But they’re not presenting to me, saying, hey, it’s headache that’s driving it. But it does seem to be part of that package of tiredness and disturbed sleep.
Dr. Anne Calhoun: Right. Well, I get the same thing. They’re coming to see me because they have daily headaches. What I want to spend time talking with them is why they have them. I tell them there are two reasons that they have chronic migraines. The first, they inherited a threshold from one parent to the other that was too low for setting off the trigeminal complex in the brain.
But the other one is, is they’re waking up tired. We’ve got to get them out of chronic migraine, get them back to where they have just the occasional headache.
Dr. David Cunnington: When you looked at that population of people with migraine and tiredness, what were some of the things that you found?
Dr. Anne Calhoun: We found a number of things. We’ve been looking first of all at just the schedule. I have a 22-point sleep history that I go through. But television or reading in bed was the most common bad habit that we were seeing. Now it’s TV, reading, texting, video games. I mean it’s everything and are on the bed. Getting up at night to urinate is very, very common. You have trouble falling asleep, taking naps.
The majority of them are using sleeping pills or medications to fall asleep. Now we don’t want a medicated sleep. A lot of them have restless leg syndrome. They’re snoring. A wide variety of sleep problems.
Dr. David Cunnington: And that’s really interesting because then in people I might see with headaches or that present to me with headaches, it just reinforces the importance of looking for coexisting sleep disorders that may be contributing to their headache syndrome.
Dr. Anne Calhoun: Yeah. I’ve said this many times. I can’t fix their headaches until we get them waking up and fresh.
Dr. David Cunnington: So then what did you go on and do? You found these associations and then you put some things in place to try and see if you can improve things. What did you actually do?
Dr. Anne Calhoun: It was such a simple study. I simply took 43 women with chronic migraine. They were averaging over a decade of daily headaches. I got their permission to enrol them in a behavioural study. So half of them got five sleep instructions. The other half got five, diet and exercise. But they were to see those.
They all had to keep a diary, come back in six weeks. When they came back, if they’ve been on the placebo instructions, we cross them over to get their …
Everybody got the right instructions at some point in the study. But if they fixed outside the bad sleep habits, only one person did not revert back to episodic. It was a lady who was sleeping with a cat. She was allergic to it. I didn’t know anybody who did that. We now know a pretty good percentage of folks sleeping with pets they’re allergic to. She actually gave the cat to her aunt. She reverted also.
But if they had three or more bad sleep habits remaining, no one reverted. I see that day in, day out, year in, year out. If they fix it, we get them out of there. If they don’t, I will try explaining to them again why it’s so important that we really got to fix the bad sleep habit.
Dr. David Cunnington: Yeah. So what were your five things that you addressed?
Dr. Anne Calhoun: First was just to allow eight hours’ time in bed, nine if they were 25 or younger. Under 25, I think I would put it at that time. But eight hours’ time in bed that’s consistent. It doesn’t vary more than half an hour one day. The second one was no TV, music, reading, texting, video games, anything in or on the bed. They would argue back – I’m reading something calming. Well, the content doesn’t matter. I was explaining to them that the problem is – it’s not the subject matter. The problem is rapid brain wave activity. They were in this beta wave EEG activity and we’re trying to get them to slow down, eventually to a delta wave. She can’t do it. If she lies down, her brain waves slow because she doesn’t have the vocabulary to lie there and think a visualisation technique.
So that part did involve a meditation. I gave them just five tablets of low dose Zolpidem, Ambien, a little five-milligram dose and they got five tablets to last seven days. So I’m going to while they practice a visualisation. Wanted something like grandmother’s house, a place they haven’t been in a long time. But it’s a real memory and bad things didn’t happen to them there. So they would just sort of wander through, looking at stuff. Well, this medicine is slowing their brain wave.
By the fourth or fifth night, they’re typically falling asleep before it starts working with – then they cut it in half, quarter, quarter, and they’re falling asleep because I conditioned them to that. Then the fourth one is the evening meal. At least four hours before bedtime and limit liquids to six ounces of liquid in three hours before bedtime. I have to look at my original instructions to see what and then the fifth one, stop all naps. Just put more pressure on sleep to consolidate it.
Dr. David Cunnington: Yeah. So there really are sleep hygiene instructions except for the – you bringing in that relaxation or that meditation.
Dr. Anne Calhoun: Right. And that was just to get them to fall asleep quickly. We’re now finding that the people who have gone all the way around – you know, the first go, get rid of the menstrual migraines. The second go, get most of these perfect. The third go, we should never again have a headache that lasts longer than one hour. But in doing that, when they wake up refreshed, they’re perfect.
Dr. David Cunnington: And then any other steps that you tried to help with that waking feeling refreshed?
Dr. Anne Calhoun: We just like as clean a sleep as we can. I like to say good diet and exercise.
Dr. David Cunnington: That’s a good point about the medications because often – particularly if people are coming to see me. They’ve got an intentional bias around sleep and they’re very focused on trying to get the sleep quality right and chasing that with meds. But probably it’s distorting sleep architecture and may not actually be a positive thing.
Dr. Anne Calhoun: Absolutely. I agree. I don’t want them on sleep medication at all. I mean they all get that one subscription, but no refills. It’s just to retrain them to fall asleep quickly.
Dr. David Cunnington: So that research that you did was around 10 years ago and you’ve got a lot of clinical experience and you’ve learned from that research. So now in 2017, what’s your approach if someone is presenting with persistent migraine headache?
Dr. Anne Calhoun: It’s absolutely this thing. My first step was that – I have a little bit of an unusual niche in the headache world in that I deal with menstrual migraine. So all women with hormonal issues, so preventing the menstrual migraine with a limiting drop in oestrogen. Then second base in the strategy is to get them back to perfect and that’s fixing the sleep. I will use some preventive medicines. I did a talk over in Stockholm a few years ago at the International Headache Congress and showed them what the database revealed, that our patients were on 25 percent. So it’s cleaning it all up.
Dr. David Cunnington: Right. Thank you very much for those insights, Anne, and thanks for your help.
Dr. Anne Calhoun: You’re so welcome. Thank you for asking me.
Dr. David Cunnington: So that’s really interesting what Anne was talking about I’m really impressed about her ability to convert people with persistent headache into having intermittent headache with what’s really actually a pretty simple sleep intervention.
Dr. Moira Junge: Yeah.
Dr. David Cunnington: Moira, what did you think?
Dr. Moira Junge: Yeah, very simple. Yeah, motherhood statements in terms of – that’s all common sense, things that – and the CBTI is really full of that too, for common sense things that you – your grandma would have told you and just basically in a nutshell meaning just respect sleep more, prioritise it, calm down, slow down, et cetera. So very impressive to say that pretty much everyone …
Dr. Moira Junge: And that in itself would improve quality of life out of sight, improve energy, improve mood and of course if those that wanted to pursue further – like, you know, a psychologist who’s interested in health issues or clinical issues, sleep issues, pain issues would take them even further. We would be able to get them just to realign. I suppose because it’s maintenance. I think it’s the maintenance over time is the trick.
Dr. David Cunnington: Yeah.
Dr. Moira Junge: Because once you might start to fill that up and then they all have it …
Dr. Moira Junge: … they might end up just getting a bit more hyper-aroused, staying up later and later. They want to fit too much into the day, not looking after themselves as much. So I guess it’s just that reminder and which we can do – we don’t need clinicians necessarily to tell us to do that like as a community. Healthcare …
Dr. Moira Junge: … in the home, starts in our schools, our neighbourhoods, our communities that we all just remind each other. You know, take it easy a bit. Slow down a bit. Have some leisure, have some balance.
Dr. David Cunnington: Yeah.
Dr. Moira Junge: Get some early nights. Lay off the booze.
Dr. David Cunnington: Yeah. I really like that. You think of what Anne did in her research study. You think of that with a step key model. It is that sort of first step and high proportion of people responded and got a great result. But then if you’ve got a subset who got a suboptimal result, then there’s more to do.
Dr. Moira Junge: That’s right.
Dr. David Cunnington: You’ve got lots more tricks in your bag that you could use to build on that initial work.
Dr. Moira Junge: Yes, without even mentioning the excitement of the mindfulness-based therapy really, MBTI, using all the CBT stuff that we previously talked about, but in using mindfulness as well. She didn’t necessarily even have that, did she? It was all really, really basic. It was really sleep hygiene in a sense for sleep advice.
Dr. David Cunnington: Yeah.
Dr. Moira Junge: There are so many more layers where people could go and I wonder – she sounds really interesting. I wonder if she would come in and do some visits to Australia and do some talks. She might even – she’s not someone who necessarily has presented in any sleep conferences. I don’t know. Has she presented it?
Dr. David Cunnington: I didn’t get a chance …
Dr. Moira Junge: Yeah. So it would be really great to talk with with her further, invite her down to Australia.
Dr. David Cunnington: We should do it. So I hope you’ve got some insights from our discussion around headaches and sleep. It certainly opened my eyes in reading more about this area to get some information together for the podcast. So thanks for triggering my professional development …
Dr. Moira Junge: Yeah, keep the suggestions coming because it’s really good for us, isn’t it? Just talking about topics that we hadn’t previously highlighted as an area of interest, but clearly there’s tons more to talk about.
Dr. David Cunnington: If you’re looking for more information on headaches, there’s a nice resource in Australia that’s part of the Brain Foundation, HeadacheAustralia.org.au.
Dr. Moira Junge: So we come to the clinical tip of the month. What’s your tip for this month, Dave?
Dr. David Cunnington: We’re going to try and keep it on topic and relevant to headaches, but relevant to other things as well and really what Anne’s research showed me – one of the things I really loved about it is how simple measures can have a big impact for people and things that as a specialist maybe like dismiss and going, “You know what? That’s not high-powered, high-tech.” You would be – sort of whiz-bang …
Dr. Moira Junge: Not impressive enough?
Dr. David Cunnington: Yeah, not impressive enough. I can’t share my masterful skills.
Dr. Moira Junge: All those years of study.
Dr. David Cunnington: Yeah. But in actual fact, the really simple things can be really powerful. So a nice reminder for me and a nice reminder for other clinicians working with people. Don’t forget the small stuff and often the small stuff can make a really big difference and don’t get seduced or distracted by the high tech whiz-bang things because sometimes we don’t need that complexity.
Dr. Moira Junge: I agree.
Dr. David Cunnington: So what’s your pick of the month, Moira?
Dr. Moira Junge: Well, just recently throughout March actually, just a couple of weeks ago, a very interesting online course was launched called A Mindful Way. I’m not sure whether we have talked about this before in the podcast. I think maybe Giselle has been a guest. No? Maybe on Sleep Hub, she has been …
Dr. David Cunnington: Yeah. She has done some interviews on Sleep Hub.
Dr. Moira Junge: Yeah. She’s a colleague and friend of both of us and she’s – she has been working on this online course for A Mindful Way really to treat insomnia, which is finally launching online. I just think that’s definitely my pick and I think it’s really good. Not just because she’s my friend and colleague but I think it’s going to be – it’s just a nice thing. It’s the first of its kind in a way of someone who has that experience and expertise in both sleep treatments and mindfulness. Giselle is a clinical psychologist.
Yeah. So that’s my tip. We will put the link on the show notes and …
Dr. David Cunnington: Yeah, that’s fantastic. I agree with that. Yeah.
Dr. Moira Junge: We’re talking about – but next month, we will talk about mindfulness in more detail.
Dr. David Cunnington: So my tip is out of a book and this tells you a little bit of insight about me. So one of my most prized books is a book from 1916 called Sleep. It’s a collection of quotes from EW Cole, published in 1916.
Dr. Moira Junge: How did you find the book from 1916?
Dr. David Cunnington: Well, it’s also a sad story. So someone I worked with about 15 years ago who knew what a sleep tragic I was, saw it at a garage sale and said, “Oh, David loves that.” So he bought it for me and gave it to me and then I was so touched by that.
Dr. Moira Junge: Yeah.
Dr. David Cunnington: It’s just an absolute gem. But there are lots of really cute, old quotes about sleep.
Dr. Moira Junge: Give us one.
Dr. David Cunnington: I will give you two. I’ve chosen two. So the first one is from Joseph Addison. Joseph Addison was born in 1672, died in 1719. Was sort of essayist in the UK. So his quote is, “My soul is quite weighed down with care and asks the soft refreshment of sleep.”
Dr. Moira Junge: How nice is that? People …
Dr. David Cunnington: It rings true today. So that’s from the late 1600s, that quote and 300 years later, it hasn’t changed. People I see in my office are still weighed down with care, looking for the refreshment of sleep.
Dr. Moira Junge: Yes. All right. Give us another one.
Dr. David Cunnington: All right. Second one, “Heaven trims our lamps while we sleep.” Right. So that was my initial reaction. See this is also from a time when lamps were candles and trimming the lamps was trimming the wick in the candle. So once you get that sort of – that analogy of it’s trimming the wick and that’s heaven. Trims our lamps while we sleep, so that you wake up in the morning and your wick has been trimmed and you’re ready to …
Dr. Moira Junge: Oh, I like that too.
Dr. David Cunnington: Yeah.
Dr. Moira Junge: Gosh, well there’s a treasure trove in there. I think we’ve got about 200 more pages.
Dr. David Cunnington: Yeah, exactly.
Dr. Moira Junge: I think we can keep dipping into that.
Dr. David Cunnington: So we didn’t come up with quotes. You now know my little secret of where they’re coming from.
Dr. Moira Junge: Thanks Dave.
Dr. David Cunnington: All right. So look out for some things that are coming up over the next months. So the sleep conferences we’ve been talking about. So Sleep 2017, which will be in Boston in June and then the World Sleep in Prague in October and Sleep Down Under in Auckland at the end of October. A little personal plug. I’m having a lovely week at Golden Door at the end of April and into May. I will be there for about seven days.
Dr. Moira Junge: We still haven’t made it there. What’s happening?
Dr. David Cunnington: Oh, sorry Moira. Must be a hiccup. It got lost in the mail.
Dr. Moira Junge: I didn’t get the memo.
Dr. David Cunnington: But on Saturday night, April of 29th, we will be talking there as a guest speaker, giving a lecture on sleep and I do have a weekend program where people come and stay for the weekend and listen to the guest lecture and during the week that I’m there, I really love just interacting with guests and got a lot to talk about sleep. And I talk to them about sleep non-stop for the whole week. So it’s pretty good fun.
Dr. Moira Junge: How to put them to sleep.
Dr. David Cunnington: Yeah, exactly. As Moira alluded to, our next episode, which will be up at the start of May, we’re going to actually talk about mindfulness and its role in sleep. We will have Dr. Giselle Withers join us as a guest co-host throughout the episode and we will talk about Giselle’s online program. But we will actually pick Giselle’s brain about mindfulness, how it can be used for sleep and a range of other things and we will give our own views on how we would use mindfulness in a sleep way.
Dr. Moira Junge: It’s a coincidence too that there’s a – it was a movement over the last few years called Mindful in May, encouraging people to take a call to action. I’m sure we will incorporate talking about that as well.
Dr. David Cunnington: Yeah, it’s a nice timing.
Dr. Moira Junge: So thanks for listening and remember to send us any suggestions via Facebook or email or …
Dr. Moira Junge: We do. We listen. Of course, if you like the podcast, make sure that you write a review because it’s always good for our ego. More importantly, it helps people find the podcast. More people can listen to it. So we really appreciate that. Spread the word. So yeah, so thanks very much for listening and we look forward to next month.
Dr. David Cunnington: Great, thanks a lot.
This podcast is not intended as a substitute for your own independent health professional’s advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health provider within your country or place of residency with any questions you may have regarding a medical condition.
