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Sleep quality and energy levels were linked to headache onset on the following day, a prospective observational study found.

Lower average sleep quality (P<0.001) and poorer-than-average sleep quality on the previous night (P<0.01) were tied to an increased likelihood of an incident morning headache, reported Kathleen Merikangas, PhD, of the National Institute of Mental Health (NIMH) in Bethesda, Maryland, and the Johns Hopkins Bloomberg School of Public Health in Baltimore, and co-authors.

Higher-than-average energy levels the day prior was linked with headaches later the next day (P<0.05), the researchers wrote in . In a subset of participants who reported perceived stress, a significant association between average self-perceived stress and later next-day headache emerged (P<0.01).

Mood and anxiety disorders were not significantly associated with incident headache, after controlling for history of migraine.

"We were surprised that the usual suspects, which were anxiety, depression, and stress as predictors of incident headaches, were superseded by sleep changes," Merikangas told MedPage Today.

Objective sleep measures from actigraphy were not associated with incident morning or evening headache, but subjective assessments were. "Probably, the subjective measures are more likely to pick up some kind of change that's going on in their brain, than what time they went to bed," Merikangas noted. "It's probably some kind of change in the system such as the autonomic nervous system, and something that's going on that's changing your brain architecture."

Migraine can be difficult to treat because of its comorbidities, especially cardiovascular disease and mood disorders, and a limited understanding of how sleep, mood, and energy interact with migraine onset, the researchers observed.

Though sleep disturbances and migraine have a well-established connection, the mechanisms involved are complex, Merikangas and co-authors noted. Links between higher levels of stress and increased energy suggest that later-day headache onset could be similar to tension-type headaches that are exacerbated by higher levels of arousal and reactivity to daily events, they added.

"What we hear all the time from patients is that, 'when I don't get enough sleep, I get a migraine. I know this is my migraine trigger," noted Angeliki Vgontzas, MD, of Brigham and Women's Hospital in Boston, who wasn't involved in the study. While several retrospective studies support this, "I think [this study] kind of confirms that not getting enough sleep the night before, at least measured by actigraphy, doesn't seem to be a migraine trigger," she told MedPage Today.

The findings raise questions about whether sleep disturbance might be an early part of a migraine attack as opposed to a trigger, Vgontzas added. "I think what this paper is telling us is that we shouldn't be counseling patients to very rigidly try to get 8 hours of sleep every night in order to prevent headache, and actually, perhaps it is even anxiety- or stress-inducing to do that," she said.

Merikangas and colleagues included participants from the . Mood and anxiety disorders were assessed with the NIMH Family Study Diagnostic Interview for Affective Spectrum Disorders, and ICHD-III headache subtypes were assessed with the NIMH Diagnostic Interview of Headache Syndromes.

A total of 477 participants completed 4,974 assessments. Most participants (61%) were female and 84% were white or Hispanic. Those with migraine history more commonly had mood or anxiety disorders.

For 2 weeks, participants completed electronic diaries using (EMA) procedures to rate their current emotional state 4 times a day on Likert scales from 1-7 for anxiousness, mood, energy, sleep quality, and for a subset sample, perceived stress. EMA assessments were scheduled 4 times a day for 2 weeks between 7 a.m. and 10 p.m., with at least an hour between assessments. Participants also wore actigraphy monitors for 2 weeks which measured sleep duration and sleep midpoints.

The researchers were limited by the study's brief observation period and its lack of economic, ethnic, and racial diversity. The study could not examine the relationship between medications and headache and was underpowered to study a full range of headache predictors. Data about stress were collected from a subsample only.

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