Conference Coverage
SAN DIEGO—A behavioral intervention for comorbid insomnia in people with chronic migraine may reduce headache frequency by approximately 50%, according to research presented at the 58th Annual Scientific Meeting of the American Headache Society. Improvements in headache frequency and sleep efficiency continue after the intervention ends, as is the case with many behavioral therapies.
More than 38% of migraineurs sleep less than six hours per night, compared with about 10% of the general population. In addition, the prevalence of insomnia is much higher among individuals with headache than among the general population. “Most people who present for treatment of migraine have insomnia, and that’s true even of episodic migraineurs,” said Todd Smitherman, PhD, Associate Professor of Clinical Psychology at the University of Mississippi in Oxford.
Todd Smitherman, PhD
Treatment Included Stimulus Control
Dr. Smitherman and colleagues conducted a randomized controlled pilot trial to study whether a behavioral intervention for comorbid insomnia could improve sleep and headache in adults with chronic migraine. The researchers enrolled 31 individuals in the study who met the diagnostic criteria for chronic migraine and insomnia. People with medication overuse were excluded from the study. Participants were randomized to cognitive behavioral therapy for insomnia (CBTi) administered in three 30-minute sessions, or to sham treatment.
Both groups received training in five skills. Participants who received CBTi were advised to adhere to a consistent bedtime that allowed eight hours in bed, to avoid other activities while in bed (eg, reading or watching TV), and to discontinue naps. These participants also were instructed to get out of bed and engage temporarily in quiet activity if they were unable to fall asleep after 30 minutes (ie, stimulus control). Finally, this group also underwent sleep restriction.
The control group received instructions to maintain a consistent liquid intake, to eat a serving of protein in the morning, to perform acupressure near the elbow, to practice range-of-motion exercises in the morning, and to eat dinner at a consistent time every evening. The same therapist administered both treatments to reduce allegiance effects.
All participants maintained daily headache diaries, completed self-report measures, and underwent actigraphy. The study’s primary outcome was reduction in headache frequency at two weeks post-treatment and at six-week follow-up.
CBTi Improved Sleep and Headache
The control group had a slightly lower headache frequency at baseline (20.5 days/month) than did the active group (22.7 days/month). The population’s mean age was 30.8, 90.3% of the sample was female, and 80.6% were Caucasian.
At two weeks post treatment, headache frequency was reduced by 26.9% for participants who received CBTi and by 36.2% for controls. At six weeks, headache frequency was reduced by 48.9% for the CBTi group and by 25.0% for controls. At six weeks, people who received CBTi also were 60% less likely to have headache, compared with controls. Individuals who received CBTi continued to improve after the intervention ended, said Dr. Smitherman. In contrast, individuals in the control group regressed toward their baseline conditions.
Participants’ insomnia symptoms were significantly correlated with the probability of headache, as well as with changes in disability. The actigraphy data indicated that CBTi produced significantly larger increases in total sleep time and sleep efficiency than sham treatment. CBTi also was associated with greater reductions in self-reported insomnia severity, compared with sham treatment.
Insomnia and Bipolar Disorder
Sleep restriction is not recommended for patients with bipolar disorder because it can promote manic episodes, said Dr. Smitherman. Alternatives for these patients include training in progressive muscle relaxation or referral to a provider for behavioral therapy.
Neurologists need larger and longer studies of behavioral therapy, Dr. Smitherman added. “We need to isolate the mechanisms of action.” One of the mechanisms appears to be that changes in sleep improve migraine, given the associations that data analyses reveal.
Suggested Reading
Calhoun AH, Ford S. Behavioral sleep modification may revert transformed migraine to episodic migraine. Headache. 2007;47(8):1178-1183.
Rains JC, Poceta JS. Headache and sleep disorders: review and clinical implications for headache management. Headache. 2006;46(9):1344-1363.
Smitherman TA, Walters AB, Davis RE, et al. Randomized controlled pilot trial of behavioral insomnia treatment for chronic migraine with comorbid insomnia. Headache. 2016;56(2):276-291.