Sleep disorders and headaches

Question 1

Sleep

Answer 1

• A physiologic state of relative unconsciousness, inaction of voluntary muscles, and the need for which recurs periodically
• Sleep stages: NREM (non-REM, delta) is 75% of sleep, the most restorative, and REM (25%) is associated w/ classical dreaming
• Sleep cycle: NREM and REM cycle (every 90 min NREM followed by about 20 min of REM)
• Over the night REM periods become longer and more intense
• Age related changes: decrease in amount of delta sleep, increase in awakenings during sleep

Question 2

Causes of excessive daytime sleepiness

Answer 2

• Usually self-induced sleep deprivation
• Obstructive sleep apnea
• Narcolepsy
• Insomnia
• Movement disorders

Question 3

Obstructive sleep apnea

Answer 3

• Respiration ceases for brief periods of time, followed by arousal from sleep
• Can be several hundred of the arousals resulting in fragmented sleep
• Obstructive: blockage of the airway
• Central: inability of central regulatory system to drive respiration
• Often accompanied by snoring
• Rx: obstruction removal via surgery, CPAP, pharmacological (avoid CNS depressants since they interfere w/ brain’s ability to be aroused)

Question 4

Narcolepsy

Answer 4

• Parts of the tetrad: excessive daytime sleepiness, cataplexy (sudden loss of muscle tone, preceded by emotionally charged stimulus), sleep paralysis (upon waking), hypnagogic hallucinations (dream-like fragments)
• Non-pharmacologic Rx: education, support, naps (10 min)
• Pharmacologic Rx: Antidepressents (SSRIs) can result in rebound cataplexy when discontinued abruptly, sodium oxybate (GHB), CNS stimulants

Question 5

Insomnia

Answer 5

• Relative lack of sleep + impairment of function
• Can include: difficulty falling asleep/maintaining sleep, waking too early, poor quality
• Can be transit (days, due to stress), short-term (3 weeks)
• Rx with good sleep hygiene, relaxation, hypnotic drugs (BZDs)

Question 6

Ideal hypnotic

Answer 6

• Rapid sleep induction
• Sufficient duration w/ no hangover
• Lack of habituation and tolerance
• Normal sleep pattern
• High therapeutic index
• Lack of drug interactions

Question 7

Sleep hygiene

Answer 7

• Regular bedtime and wake up time
• Regular exercise early in day
• Avoid naps
• No heavy/spicy foods, or late meals/drinks
• Bedroom cool, dark, quiet
• Minimize caffeine, EtOH, stress

Question 8

Different hypnotics

Answer 8

• Diphenhydramine: histamine (H1) antagonist and anticholinergic (gives sympathetic sx)
• Barbiturates (not used)
• Antidepressants: highly sedating, can also be anticholinergic
• Benzodiazepines: first line of Rx for insomnia
• Non-BZD BZD-receptor agonists: the Z drugs, not as widely used
• Melatonin-receptor agonists: short acting, reduces sleep latency (but inconsistent on total sleep time)

Question 9

Severe headache differential

Answer 9

• Migraine/cluster
• Subarachnoid hemorrhage (SAH)
• Hydrocephalus
• Infection
• Eyes
• Cervicogenic
• Tests: CT head, LP (hb, bili), anteriogram

Question 10

Sx for SAH

Answer 10

• Systemic: fever, weight loss
• Neurologic: confusion, seizures
• Onset: sudden
• Older: >50
• Previous health Hx: 1st headache?

Question 11

Migraine Dx

Answer 11

• History: Past headache history, social, family Hx, headache impact
• Normal PE
• No imaging needed unless abnormal signs
• Criteria of migraine: any 2 Sx (unilateral, throbbing, worsened by movements, moderate or severe) plus any one Sx (nausea or vomiting, photo/phonophobia)
• Clinical course: prodrome (cause), aura (visual, sensory association), headache, postdrome

Question 12

Pathogenesis of headache

Answer 12

• Generated in brainstem (pons), which stimulates CN V thus causing release of neuropeptides and constriction of blood vessels
• There is neuronal hyperexcitability (esp in occipital cortex)
• Rx: pharmacologic treatment of even mild pain, and within 15 min of onset

Question 13

Cluster headache

Answer 13

• Starts same time same day each year (unique time pattern)
• Usually in males, onset 20-40 yo
• Severe, excruciating, lasts 15min - 3 hours
• Restless pt (as opposed to migraine: don’t want to do anything)
• Starts in hypothalamus
• Rx: 100% O2, pharmacologic

Question 14

Rebound headache

Answer 14

• Analgesic rebound: use of more than 10-15 pills of common NSAIDs per week
• Causes brain to sensitize to normal pain threshold, thus removing the drug increases pain perception