Exploring daytime sleepiness during migraine

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1 Exploring daytime sleepiness during migraine J.H.M. TULEN 1, D.L. STRONKS 1,2, L. PEPPLINKHUIZEN 1, J. PASSCHIER 2 DEPARTMENTS OF PSYCHIATRY 1 AND MEDICAL PSYCHOLOGY & PSYCHOTHERAPY 2, UNIVERSITY HOSPITAL ROTTERDAM DIJKZIGT AND ERASMUS UNIVERSITY ROTTERDAM, THE NETHERLANDS Introduction Migraine is a paroxysmal disorder, with attacks of unilateral, pulsating headache associated with nausea, vomiting, photophobia and phonophobia (1). It is estimated to occur in about 10% of the Dutch population, with females being more affected than males. The repeated recurrence of migraine attacks significantly reduces quality of life and leads to impaired functioning (physically, emotionally, and socially) both at home and at work (2,3). Dependent on the severity, a migraine attack can necessitate bed rest and/or reduced activity level, thereby disturbing normal diurnal rest-activity patterns (and sleep-wake patterns). The research done on daily functioning during an actual migraine attack is limited and exclusively based on self-report measures (4). We do not know how these subjective reports of migraine-induced disability relate to the behavioral aspects of daily functioning. Yet, quantification of the patient s actual behavior in connection to their subjective perspective of level of functioning during a migraine attack can provide a better understanding of the relationships between diurnal mobility patterns, migraine and effectiveness of therapeutic interventions. Sofar, no standardized studies in this area of research have been performed. We evaluated the feasibility of using accelerometry (5,6) as a method to assess the effects of migraine attacks on normal daily activities (body posture, physical and locomotor activities) by performing ambulatory 24-hr measurements during a headache free baseline period, as well as during and after an actual attack (acute treatment varied per patient) in the habitual environment of migraine patients. Simultaneously, repeated subjective assessments of sleep quality, mood, pain, level of functioning, and daytime sleepiness were obtained by means of daily logs. In this report we focus on our findings regarding daytime sleepiness during migraine with the aim to explore whether a migraine attack induces changes in daytime sleepiness, because sleepiness may also influence daily functioning. At present, we have no knowledge about the relationships between migraine attacks and feelings of sleepiness, with the exception of reports of increased sedation as a possible sideeffect of various anti-migraine drugs (e.g., 9). We will interpret the sleepiness 163

2 findings in relation to the effects of the migraine attacks on subjective level of functioning and daytime fatigue. Methods Subjects Six female migraine patients (mean age: 39.8 years, range: 29-49), recruited by means of advertisements, participated in this study. The diagnosis migraine (criteria: Headache Classification Committee of the IHS, 1) was confirmed by a neurologist of the University Hospital Rotterdam Dijkzigt. Patients with a positive history of drug abuse or psychiatric illness, or current medical illness other than migraine, were excluded from the study. The patients used their habitual anti-migraine medication for the treatment of the migraine attack, but did not use prophylactic anti-headache medication during the study; two patients used no medication during their migraine attack (patients 1 and 3). Procedures and measurements: Repeated measurements of 24-hour patterns of physical activities (activity monitoring by means of body-mounted accelerometers on the upper legs and trunk), as well as repeated subjective assessments of mood, level of functioning, and sedation (daily logs), were obtained during a headache free baseline period, as well as during and after a migraine attack, in the habitual environment of the patients. A spontaneous migraine attack was documented by measuring migraine patients from the onset of their migraine attack until two days after the attack. Apart from these measurements, two consecutive 24-hour recordings (baseline) of the same patients were made during a headache free period. These baseline measures were scheduled before the measurements during the migraine attack. Within the daily log, the following self-rating scales were filled in by the patients at breakfast, lunch, dinner, before sleep, and at onset of migraine and after 2 and 4 hrs of migraine: a) the Profile Of Mood States (POMS; validated Dutch version; 7): the POMS comprises 5 subscales: vigor, fatigue, tension, anger, and depression, b) the Level of Functioning scale (LOF; Passchier et al., in preparation): the LOF consists of a short Guttman scale with items ranging from is only capable of lying on bed to is capable to perform heavy physical activities, and c) the Stanford Sleepiness Scale (SSS, Dutch translation; 8): the SSS consists of a 7-point scale with items ranging from feeling active, alert to cannot stay awake, sleep onset appears imminent. We will report the findings of the SSS, the LOF scale, and the subscale Fatigue of the POMS, of the baseline period and at the onset of measurements during the migraine attack (when all patients were still drug-free). 164

3 Statistical analysis Per patient, the migraine data were evaluated versus the mean values obtained during the second day of the baseline period (first day was considered an habituation period, although the mean data of the first day did not significantly differ from the mean data of the second day). Per parameter, differences between the two conditions were analyzed by means of Wilcoxon tests. Because patients 1 and 3 used no anti-migraine treatment, the complete SSS data of these patients during baseline, migraine and recovery periods are presented as illustrations of changes in sleepiness during untreated migraine. Results Effect of migraine on sleepiness, fatigue and level of functioning (fig.1) The migraine attacks of the patients varied in severity at the onset of measurements between moderate (patients 2 and 4) and severe (patients 1, 3, 5, and 6). Patients 1 and 2 were able to continue their daily activities, whereas patients 3, 4, 5, and 6 had to lie down during at least part of their attack period. Migraine caused an increase in Sleepiness, as compared to baseline, in all patients (increase always > 25%; baseline mean[sd]: 2.6[0.8], migraine: 5.5[1.1]; Wilcoxon test: p<.05; fig.1). Although Level Of Functioning decreased significantly during migraine in comparison with baseline values (baseline: 15.6[7.1], migraine: 2.3[1.1]; p<.05; fig.1), it did not lower much in patients 1 and 2 (about 10%) who were able to continue their activities. Migraine also significantly increased subjective feelings of fatigue (baseline: 2.6[1.2], migraine: 15.0[7.4]; p<.05; fig.1); only in patient 2 this increase was relatively small (13%). Figure 1: Per patient, the change during a migraine attack (versus baseline) in sleepiness, level of functioning, and fatigue, expressed as percentage of the maximal range of each scale. SSS: Stanford Sleepiness Scale; LOF: Level Of Functioning scale; Fatigue: subscale fatigue of the Profile Of Mood States. 165

4 Subjective Sleepiness during untreated migraine (fig.2) Patient 1: The migraine attack of patient 1 was monitored from about 13:00 hrs onwards. Headache at starting point was severe, but soon reduced to mild intensity (after 2 hrs); the patient reported a significant improvement of headache after 4 hrs. During the migraine attack sleepiness was increased, although the patient was able to continue with her daily activities. The sleepiness scores of the recovery day resembled the data obtained under baseline conditions (fig.2a). Patient 3: This patient suffered from a very severe migraine attack, lasting 2 days; the patient stayed in bed from the onset of measurements (at about 13:00 hrs) till most of the next day. A significant improvement of headache was reported after about 10 hrs of measurement. During this migraine period the patient scored maximal on the SSS (maximum score=7); also during the first recovery day, when the patient still spend 84% of the daytime period in bed, the sleepiness scores remained elevated in relation to the daytime period during baseline (fig.2b). Figure 2: Sleepiness during untreated migraine: SSS scores during baseline, migraine and subsequent recovery periods of patients 1 (A) and 3 (B). Discussion Migraine constitutes a complex set of symptoms, the most important one being severe pain. Apart from this feature, migraine-induced disability consists of a range of complaints comprising reduced quality of life, reduced level of functioning, and lowered mood. In this exploratory study, we have provided some first evidence showing the presence of sleepiness during untreated migraine. Increased sleepiness occurred in all patients. It appeared not unequivocally related to requirements of bed rest or reduced level of functioning, yet, to a certain extent it did correspond with increased feelings of fatigue. The impor- 166

5 tance of increased sleepiness and fatigue during migraine and their possible connection with alterations in diurnal patterns of behavioral activities need to be further clarified in studies with more subjects before and during (acute treatment of) migraine. The fact that some effective anti-migraine drugs may induce sedation as a side-effect (9) makes the study of these relationships more relevant but also more complex. The study was supported by a grant from Glaxo Wellcome BV. References 1 Headache Classification Committee of the International Headache Society: Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 8(suppl 7):10-73, Kryst S, Scherl E. A population-based survey of the social and personal impact of headache. Headache 34: , Passchier J, Andrasik F. Migraine, Chapter 31. Psychological Factors. In: Olesen J, Tfelt-Hansen P, Welch KMA, eds. The Headaches New York, Raven Press, 1993, pp: Stewart WF, Lipton RB, Kolodner K, Liberman J, Sawyer J. Reliability of the migraine disability assessment score in a population-based sample of headache sufferers. Cephalalgia 19: , Bussmann JBJ, Reuvekamp R, Veltink PH, Martens WLJ, Stam HJ. Validity of an instrument for ambulatory measurement of mobility activities. Pain 74: , Tulen JHM, Bussmann JBJ, van Steenis HG, Pepplinkhuizen L, Man in t Veld AJ. A novel tool to quantify physical activities: ambulatory accelerometry in psychopharmacology. J Clin Psychopharmacol 17: , Wald FDM, Mellenbergh GJ. De verkorte versie van de nederlandse vertaling van de Profile Of Mood States (POMS). Ned T Psychol 45:86-90, Hoddes E, Zarcone V, Smythe H, Phillips R, Dement W. Quantification of sleepiness: a new approach. Psychophysiology 10: , Schoenen J. Acute migraine therapy: the newer drugs. Current Opinion in Neurology 10: ,

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7 Effect of non-pharmacological treatment on polysomnography, sleep/wake diary and questionniares in patients with primary insomnia INGRID VERBEEK (1) & YVON SWEERE (2) 1 CENTER FOR SLEEP AND WAKE DISORDERS KEMPENHAEGHE, HEEZE 2 CENTER FOR SLEEP AND WAKE DISORDERS MCH WESTEINDE HOSPITAL, THE HAGUE Introduction Primary insomnia is a subjective complaint of disturbed duration, quality and efficiency of sleep. When the criteria of the International Classification of Sleep Disorders (ICSD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) are combined, the definition of primary insomnia is as follows: primary complaint of sleep onset and/or sleep maintenance insomnia or non-refreshing sleep during at least one month the sleep complaints lead to dysfunction during the day (social, work) the sleep disorder does not occur exclusively in the course of narcolepsy, sleep related breathing disorder, circadian rhythm disorder or parasomnie. the sleep disorder does not occur exclusively in the course of a psychiatric disorder (depression, general anxiety disorder) the sleep disorder is not the result of direct physiological effects of drugs or medicine or a somatic disorder there are indications of learned sleep-preventing associations (trying too hard too sleep, conditioned arousal to bed-room or sleep-related activities). Primary insomnia is sustained by behavioral, cognitive and physiological factors. Non pharmacological therapy (NPT) has been proven effective in treating primary insomnia (1-6). Most studies used subjective measures to measure the effects of NPT on sleep. Despite the fact that insomnia in the first place is a subjective complaint, objective evaluation of NPT is important because polysomnography (PSG) is still seen as the golden standard in the evaluation of sleep. Furthermore, the influence of NPT on quality of life and psychological well being has only been established in a few studies. In this ongoing two-center study we investigated the effect of short-term NPT on polysomnography (PSG), sleep/wake diary (SD) and various questionnaires. 169

THE SLEEP DIAGNOSIS LIST (SDL): A QUESTIONNAIRE FOR SCREENING GENERAL SLEEP DISORDERS

THE SLEEP DIAGNOSIS LIST (SDL): A QUESTIONNAIRE FOR SCREENING GENERAL SLEEP DISORDERS Sweere Y 1, Kerkhof GA 2, De Weerd AW 1, Kamphuisen HAC 1, Kemp B 1 & Schimsheimer RJ 1 1 Centre for Sleep and Wake