Sleep and headache disorders share a complex, bidirectional relationship. This review summarizes current evidence on various aspects of sleep and three primary headache disorders—migraine, tension-type headache, and cluster headache. We also suggest inclusion of a clinical questionnaire and treatment pearls for clinicians treating patients presenting with headache and sleep complaints. Several sleep disorders, particularly insomnia and restless legs syndrome, are highly prevalent in patients with migraine. Insomnia may contribute to or be a manifestation of a more severe migraine phenotype. Poor sleep is associated with worse pain severity for chronic tension type headache. Circadian studies in cluster headache further confirm hypothalamic and possibly, the trigeminal ganglion control. Behavioral interventions and pharmacologic considerations may optimize sleep and headache outcomes. Sleep symptoms and headache frequently co-occur, with emerging evidence identifying underlying networks and drivers. Individualized sleep assessments and interventions are an important part of comprehensive headache treatment for many patients.

To provide a working definition of underserved populations in headache medicine for use in clinical and research settings. Prior research has identified disparities in headache care access, disease prevalence and burden in US populations by geographic location, poverty or disability status and for members of racial, ethnic or sexual and gender minority groups, or vulnerable groups such as new migrants. Research studies typically exclude other populations (pediatric, geriatric and pregnant/breastfeeding), which may limit the quality of headache care they receive. We propose that underserved populations in headache medicine is broadly defined as those facing barriers in access to headache care – specifically, individuals living in rural or geographically underserved areas, who are uninsured, underinsured or living in poverty, with disabilities, from historically marginalized racial/ethnic groups, who are LGBTQIA+, or vulnerable groups such as new migrants, asylum seekers and those with an undocumented status.

OBJECTIVE:This study was conducted to identify patient characteristics and medication factors associated with perceived comfort with migraine treatments and control of migraine symptoms. BACKGROUND:Patient perceptions of migraine treatment influence adherence and outcomes, yet little is known about their underlying drivers. Our study objective was to identify clinical features of migraine associated with comfort and perceived control of symptoms, and medication classes associated with higher patient comfort and efficacy. METHODS:Participants in the Headache Assessment via Digital Platform in United States (HeAD-US) study completed a cross-sectional survey on demographics, migraine burden, mood, disability, and medication use between September and November 2023. Comfort and control were defined using corresponding items from the Migraine Treatment Optimization Questionnaire and categorized as "high" or "low." We compared patient characteristics, clinical features, and medication classes by reported comfort and control. RESULTS:Among 5717 participants (mean age, 41.7 ± 13.0 years; 92.1% female), 58.5% reported high comfort with migraine treatments, whereas only 27.5% reported high control of migraine symptoms. High comfort was associated with fewer monthly headache days (mean, 9.9 vs. 14.2; p < 0.001), lower migraine symptom severity (median Migraine Symptom Severity Score 18 vs. 19; p < 0.001), and lower disability (Migraine Disability Assessment Score, severe: 72.7% vs. 91.2%; p < 0.001) and mood symptom scores (Patient Health Questionnaire-4 severe: 9.5% vs. 21.0%; p < 0.001), as well as income, education, and employment status. High perceived control showed similar associations with monthly headache days (mean, 9.0 vs. 12.7; p < 0.001), migraine severity (median Migraine Symptom Severity Score, 18 vs. 19; p < 0.001), disability (severe: 66.0 vs. 85.8; p < 0.001), and mood symptoms (severe: 7.6 vs. 16.9; p < 0.001), and was associated with employment status but not income or education. Among those on monotherapy, gepants and triptans were associated with higher comfort and efficacy than over the counter medications or opioids/barbiturates/ergots. For preventive therapy, β blockers and botulinum toxin were associated with the lowest perceived comfort and efficacy. CONCLUSION:Perceived comfort and control were linked to headache frequency, severity and disability, and mood symptoms. Medication class use influenced perceptions, with gepants and triptans rated most favorably. These findings underscore the importance of incorporating patient perspectives into treatment planning, with particular attention to mood, disability, and choice of medication.

Abstract Introduction Migraine is a lifelong disorder characterized by disabling headache attacks that affects about 1 billion people worldwide. Previous findings in clinical cohorts and population-based studies report that insomnia is associated with migraine. However, there are no studies on the association between migraine and insomnia in general population samples that include polysomnography. The aim of this study is to investigate whether insomnia phenotypes are associated with an increased risk of migraine in a large random general population sample. Methods A total of 1741 participants from a random sample of the Penn State Adult Cohort (52.3% women, aged 48.79± 13.56) underwent 8-hour polysomnographic evaluation. Migraine status was defined by the participant’s response to “Have you ever had migraine headaches?”, insomnia was defined by the presence of chronic insomnia lasting ≥ 1 year or complaints of difficulty falling asleep, staying asleep, nonrestorative sleep, or early morning awakening. Normal sleepers were defined by the absence of insomnia or OSA. Objective short sleep duration (SSD) was defined as < 6 hours sleep based on polysomnography. Binary logistic regression was performed controlling for age, sex, race, BMI, mental health problems, i.e., depression/anxiety, years of education, smoking, alcohol consumption, caffeine use and sampling weight. Results The prevalence of migraine was 13.5%. Compared to normal sleepers, insomnia but not OSA was associated with significant risk for migraine (OR=1.47, 95%CI=1.69-2.02, p=0.018; OR:1.11, 95%CI=0.60-2.05, p=0.722, respectively). Further analysis showed that, the insomnia normal sleep duration (INSD) phenotype but not insomnia short sleep duration phenotype (ISSD) was associated with significant risk for migraine compared to normal sleepers with normal sleep duration (OR=1.60, 95%CI=1.07-2.35, p=0.02). Conclusion Our data suggest that migraine is associated with the INSD phenotype. These findings are consistent with previous reports that INSD phenotype is associated with higher levels of depression and anxiety compared to ISSD. These differences further validate the concept of phenotyping of insomnia based on objective sleep duration with therapeutic implications i.e., INSD associated with migraine may respond better to behavioral treatments than medication. Support (if any)

OBJECTIVE:To examine circalunar rhythms in migraine headache occurrence in a prospective cohort of 98 adults with episodic migraine. BACKGROUND:Migraine is a prevalent neurological disorder characterized by paroxysmal attacks. While time-of-day and seasonal rhythmicity in migraine occurrence have been described, little is known about circalunar patterns. Understanding these rhythms may inform headache prediction and guide personalized preventive medication timing. METHODS:We performed a secondary, post-hoc analysis using data from a prospective cohort study (March 2016-October 2017). Participants completed twice-daily electronic diaries, recording various characteristics including headache, and, when applicable, menstrual cycle timing. Participants wore wrist actigraphs for 6 weeks. We tested for a 30-day circalunar rhythm in headache risk at the population-level. We then examined for lunar synchronized rhythms in individuals, adjusting our analysis for participant-specific factors and differences in baseline headache risk. Sleep characteristics and menstrual timing were assessed as potential mediators of the relationship between lunar phase and headache occurrence. RESULTS:Ninety-eight participants were followed for a median length of 43 days (interquartile range [IQR]: 42-45 days) with an average of 24.2% (standard deviation [SD] 13.2) of those days being headache days. Population-level analysis showed a significant relationship between lunar phase and headache risk (trough-to-peak odds ratio: 1.2 [95% confidence interval {CI}: 1.04, 1.49]). Individual-level analysis, adjusted for age, sex/menopausal status, and preventative medication use, showed 1.34 (95% CI: 1.1, 1.72) times higher headache odds at lunar cycle peak versus trough. Risk peaked 1-2 days before new moon. Neither sleep characteristics nor menstrual timing appeared to mediate the lunar phase-headache relationship. CONCLUSIONS:Headache risk varied with the lunar cycle, with 34% higher odds shortly before new moon compared to before full moon. Sleep and menstrual cycle timing did not appear to explain this relationship, suggesting underlying chronobiological mechanisms. Additional studies are needed to confirm these findings and characterize individual variability in rhythmicity. PLAIN LANGUAGE SUMMARY:

Background/Objective Underserved populations have worse access to neurologic care and higher risk for worse headache disease burden. We embedded a neurology clinic offering headache services within a primary care clinic treating an underserved population in Boston, Massachusetts, United States. We describe the results of a retrospective review of 1439 outpatient visits during the first three years of operation. Methods Electronic medical record data on demographics, visit types, diagnoses, and medications were extracted and summarized from patient visits completed at the embedded neurology clinic from October 2, 2020, to January 5, 2024. We also reviewed clinic utilization and consult completion rates. Results Over three years, the embedded neurology clinic completed 1439 visits, of which 687 (47.6%) were new patient visits. The consult completion rate was 73.7% (244/331). Patients had a mean age of 52.1 (SD 17.5) years, were 78% women, 68% Hispanic ethnicity and 53% Medicaid/Medicare (public) insurance. The most common diagnosis was a headache or facial pain disorder (46.2%), with migraine diagnoses representing 1/3 of all new patient diagnoses. Of patients diagnosed with migraine, 26.6% were diagnosed with chronic migraine in new patient visits, 48.1% were prescribed an American Academy of Neurology guideline-concordant migraine preventive medication (1/3 of those prescriptions for a CGRP mAB or OnabotulinumtoxinA), and 52.6% were prescribed a guideline-concordant migraine-specific abortive medication (triptan, dihydroergotamine, or gepant). Conclusion Embedding neurologic services within community health centers is a promising model to provide access to headache care for patients from underserved populations. One-third of patients seen received a migraine diagnosis that made them eligible for targeted, disease-specific treatment. Longitudinal studies are needed to evaluate the impact of embedded clinics on migraine-related disability and healthcare utilization.

This review aims to critically analyze research on the association between sleep and migraine, examine shared pathophysiology, and propose treatment approaches. Sleep disorders, such as insomnia and restless legs syndrome, have significant comorbidity with migraine and are associated with higher migraine burden. Across the migraine attack, sleep symptoms are commonly reported during the prodrome and fatigue dominates the postdrome. Neurobiological studies support shared neuroanatomical structures and neurotransmitters, including the hypothalamus, pituitary adenylate cyclase-activating polypeptide (PACAP), dopamine, serotonin, calcitonin gene-related peptide (CGRP), and orexin. Clinical trials suggest that treating insomnia, particularly with cognitive behavioral therapy, can reduce migraine frequency and severity, offering a dual benefit for patients. Understanding the shared mechanisms and clinical overlap between sleep disturbances and migraine can inform integrated, multimodal treatment strategies. Further research is needed to investigate causal relationships and optimize patient-centered care.

Study objectives:To examine the association between self-reported sleep duration on migraine frequency and disability. Methods:We conducted a cross-sectional analysis from the Headache Assessment via a Digital Platform in the United States (HeAD-US) Study, a survey of adult users of the Migraine Buddy App. Participants reported average nightly sleep duration, headache features and completed the Perceived Stress Scale-4, the Migraine Disability Assessment Test and the Patient Health Questionnaire-4 for anxiety and depression. Sleep duration was categorized as short (≤6 hours), normal (7-9 hours) and long (≥10 hours). Migraine diagnosis adhered to the International Classification of Headache Disorders-3. Results:The 6267 participants had a mean age of 41.5±13.1 years, were 90.8% female and had a mean sleep duration of 6.92 hours (SD 1.32, range 2-15). Compared to normal sleepers, short sleepers had higher risk of more frequent monthly headache days (RR = 1.128, 95% CI: 1.067-1.192) and disability (RR = 1.167, 95% CI: 1.106-1.231). Long sleepers had greater risk of more frequent monthly headache days (RR = 1.274, 95% CI: 1.049-1.464) and disability (RR = 1.699, 95% CI: 1.446-1.997). In mediation models, short sleep was linked to approximately 1.3 extra monthly headache days and long sleep to approximately 3 extra days, with stress accounting for only part of these effects. Conclusions:Unhealthy sleep duration, particularly long sleep, is associated with greater migraine burden, characterized by increased headache frequency and disability. Perceived stress partly mediated but did not fully account for these relationships. Statement of significance:This study is the first to comprehensively report on associations of unhealthy sleep duration with migraine burden in a large population of adults with migraine. Adults who report sleeping too little (6 hours ore less per night) or too much (10 hours or more per night) on average have more frequent and disabling migraine. Short sleep was linked to approximately 1.3 extra monthly headache days and long sleep to 3 extra days, with stress accounting only for part of these effects.

OBJECTIVE:To quantify the prevalence of migraine and examine its association with sleep disorders, patterns, and symptoms in adults in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). We hypothesized that migraine would be associated with insomnia but not sleep apnea. BACKGROUND:Sparse research has examined migraine prevalence and sleep comorbidities in underrepresented racial and ethnic groups in the United States. Hispanic/Latino adults in the United States may be at risk for worse health outcomes due to disparities in health-care access and socioeconomic stressors. METHODS:We analyzed data collected during the baseline examination (March 2008-June 2011) from the HCHS/SOL, a community-based cohort study of self-identified Hispanic/Latino adults in the United States. The exposure was self-reported medical diagnosis of migraine, and primary outcomes were obstructive sleep apnea (apnea-hypopnea index ≥ 15 events/h from at-home sleep testing) and insomnia (≥ 9 on the Women's Health Initiative Insomnia Rating Scale). Exploratory outcomes included self-reported sleep duration, timing, sleeping pill use, and naps. We compared weighted differences in outcomes by migraine status, adjusting for age and sex in all reported models. RESULTS:Our analytical sample included HCHS/SOL participants who completed questionnaires on sleep and migraine (16,325). The mean age (standard deviation) was 41.1 (31.7) years, 52.2% identified as female, and 39.5% had a body mass index ≥ 30 kg/m2. Lifetime prevalence of migraine was 15.9% (95% confidence interval [CI]: 15.0, 16.8; 23.6% [95% CI: 22.2, 25.0] of females and 7.5% [95% CI:6.6, 8.5] of males). Those with migraine were more likely to be unemployed (50.8% vs. 36.2%) and to have a household yearly income of < $20,000 (50.9% vs. 45.5%). There was no association between migraine and obstructive sleep apnea (odds ratio [OR] 0.98 [95% CI: 0.76, 1.26]) or napping (OR 0.92 [95% CI: 0.81, 1.06]). Compared to individuals without migraine, those with migraine were more likely to have insomnia (OR = 1.87; 95% CI: 1.62, 2.15) and to use sleeping pills (OR = 2.16; 95% CI: 1.80, 2.60) in sex- and age-adjusted models. Individuals with migraine also had shorter mean sleep duration (7.88 ± 2.5 h vs. 8.00 ± 2.1 h, β = -0.20; 95% CI: -0.30, -0.09) and later bedtimes (11:28 p.m. ± 5.1 h vs. 11:17 p.m. ± 4.2 h, β = 16.85; 95% CI: 3.58, 30.13; weekdays) in sex- and age-adjusted models. CONCLUSION:Self-reported medical diagnosis of migraine is common in Hispanic/Latino adults, especially females. Migraine is not associated with obstructive sleep apnea. Consistent with non-Hispanic/Latino populations, migraine is associated with insomnia in the HCHS/SOL.

We aim to critically review animal and human studies of the glymphatic system in migraine and propose a model for how the glymphatic system may function in migraine, based on the available evidence. Early studies in animal models report migraine attacks temporarily disrupt glymphatic flow. Human imaging studies suggest chronic migraine may be associated with alterations in glymphatic system function, albeit with conflicting results. Presently, it remains unknown whether repetitive migraine attacks or frequent nights of insomnia impair glymphatic system function over time in those with migraine, and whether alterations in glymphatic function could contribute to worsening migraine disability or risk for cognitive disease. Longitudinal studies of glymphatic function in patients with migraine and insomnia, with inclusion of cognitive assessments, may be informative.

Angeliki Vgontzas declares no conflict of interest.

To review replicated and highlight novel studies of sleep in children and adults with episodic and chronic migraine. Attack-related sleep symptoms are most common in the prodrome and may represent early activation of the hypothalamus rather than migraine triggers. Interictally, patients with migraine report poor sleep quality and high rates of insomnia symptoms. Cognitive behavioral therapy for insomnia in adults and adolescents with chronic migraine and comorbid insomnia results in significant improvement on their headache burden. Thus far, objective studies report that migraine per se is a not associated with sleep apnea. At the present time, there is minimal evidence that migraine is under circadian influence. The current body of evidence suggests that the insomnia symptoms and poor sleep quality commonly reported by patients with migraine are not attack-related but occur interictally and are a marker of worsening disease. The development of clinical guidelines to approach sleep symptoms and expansion of CBT-I trials in those with episodic migraine would be clinically valuable.

Objective: To examine the relationship between habitual caffeinated beverage consumption and headache frequency, duration, and intensity in a prospective cohort of adults with episodic migraine. Background: Caffeine is a commonly ascribed headache trigger in adults with migraine and clinicians may counsel patients to avoid caffeinated beverages; however, few studies have examined this association. Methods: From March 2016 to August 2017, 101 adults with physician-confirmed episodic migraine completed baseline questionnaires, including information about caffeinated beverage consumption. For 6 weeks, they reported headache onset, duration, and pain intensity (scale 0-100) on twice-daily electronic diaries. Ninety-seven participants completed data collection. We examined associations between self-reported habitual caffeinated beverage consumption at baseline and headache outcomes prospectively captured over the following 6 weeks, adjusting for age, sex, and oral contraceptive use. Results: The adjusted mean headache days per month was similar among the 20 participants reporting no habitual intake (7.1 days, 95% confidence interval [CI] 5.1-9.2), the 65 participants reporting 1-2 servings/day (7.4 days, 95% CI 6.1-8.7), and the 12 participants reporting 3-4 servings/day (5.9 days, 95% CI 3.3-8.4). Similarly, mean headache duration (no servings/day: 8.6 h, 95% CI 3.8-13.3; 1-2 servings/day: 8.5 h, 95% CI 5.5-11.5; 3-4 servings/day: 8.8 h, 95% CI 2.3-14.9) and intensity (no servings/day: 43.8, 95% CI 37.0-50.5; 1-2 servings/day: 43.1, 95% CI 38.9-47.4; 3-4 servings/day: 46.5, 95% CI 37.8-55.3) did not differ across levels of caffeinated beverage intake, though estimates were imprecise. Conclusions: We found no association between habitual caffeinated beverage intake and headache frequency, duration, or intensity. These data do not support a recommendation that patients with episodic migraine should avoid consuming caffeine. Further research is needed to understand whether deviating from usual caffeine intake may trigger migraine attacks.

To describe the design, implementation, and evaluation of a nerve block training program for neurology residents.

Using the Sleep Regularity, Satisfaction, Alertness, Timing, Satisfaction, and Duration (Ru-SATED) sleep health framework, we examined the association between multidimensional sleep health and headache burden in a cohort of 98 adults with episodic migraine. Participants wore wrist actigraphs and completed twice-daily electronic diaries regarding sleep, headaches, and other health habits for 6 weeks. We calculated separate composite sleep health scores from diary and actigraphy assessed measures using the Ru-SATED framework. We used adjusted multivariable linear regression models to examine the association between composite sleep health scores and headache frequency, duration, and pain intensity. Among 98 participants (mean age: 35 ± 12 years; 87.8

Obesity and migraine are often comorbid. Poor sleep quality is also common among individuals with migraine and may be influenced by comorbidities such as obesity. However, understanding of migraine’s relationship with sleep and the potential exacerbating effect of obesity remains limited. This study evaluated the associations of migraine characteristics and clinical features with sleep quality among women with comorbid migraine and overweight/obesity and assessed the interplay between obesity severity and migraine characteristics/clinical features in relation to sleep quality. Women seeking treatment for migraine and obesity (n = 127; NCT01197196) completed a validated questionnaire assessing sleep quality (Pittsburgh Sleep Quality Index-PSQI). Migraine headache characteristics and clinical features were assessed using smartphone-based daily diaries. Weight was measured in-clinic, and several potential confounders were assessed using rigorous methods. Nearly 70% of participants endorsed poor sleep quality. Greater monthly migraine days and the presence of phonophobia related to poorer sleep quality, and specifically poorer sleep efficiency, controlling for confounders. Obesity severity was neither independently associated nor interacted with migraine characteristics/features to predict sleep quality. Poor sleep quality is common among women with comorbid migraine and overweight/obesity, although obesity severity does not appear to uniquely relate to or exacerbate the association between migraine and sleep in this population. Results can guide research on mechanisms of the migraine–sleep link and inform clinical care.

Purpose of Review We review research on sleep symptoms and disorders in patients with episodic migraine and propose a framework for evaluating sleep symptoms in this patient population. Recent Findings Patients with episodic migraine consistently report poorer sleep on validated self-reports compared to those without migraine. In polysomnographic studies, children with migraine have objectively shorter sleep duration and lower percentage of REM sleep interictally. Prospective actigraphy studies in adults and children suggest that there are no significant changes in sleep duration, efficiency, or quality in the night before or after a migraine attack. Summary The relationship between sleep and migraine is multifaceted. Patients with episodic migraine report poorer sleep and have higher risk of some sleep disorders, including insomnia, sleep-related bruxism, and restless legs syndrome. Sleep screening questions may be incorporated into headache evaluations. Care should be taken to avoid headache medications that may exacerbate sleep symptoms. Evidence-based treatments for insomnia may be initiated while patients await CBT-I. Further studies are needed to assess whether treatment of comorbid sleep disorders results in improvement in migraine-related burden in those with episodic migraine.