Sleep deprivation headache

JN Blau

CEPHALALGIA Blau JN. Sleep deprivation headache. Cephalalgia 1990;10:157-60. Oslo. ISSN
0333-1024

Headaches due to insufficient or interrupted sleep are generally labelled "tension headaches"
of psychogenic origin. In 25 healthy subjects, variable amounts of sleep loss (1-3 h for 1-3
nights) caused headaches lasting from 1 h to all day. The headache was most frequently a
dull ache, a heaviness or a pressure sensation felt in the forehead and/or at the vertex.
Simple analgesics, purchaseable without a doctor's prescription, completely or markedly
reduced the head pain in 20-60 min. Headaches due to insufficient sleep differ from tension
headaches in their site, duration and response to analgesics. Assuming that pain implies a
regional dysfunction, headaches caused by sleep loss provide support for the notion that
sleep has a restorative function in the brain. • Headache, sleep deprivation, sleep function

JN Blau, The National Hospital for Nervous Diseases, Queen Square, London WC1N 3BG,
and City of London Migraine Clinic, London EC1M 6DX; Accepted 11 May 1990

Prolonged sleep is a recognized cause of headaches, but insufficient sleep is rarely mentioned in headache
monographs or in the: sleep literature. Yet, in a study of 327 medical and dental students, 127 (38.8%)
experienced headaches due to sleep loss (Blau, unpublished observations). The characteristics of this type of
headache, not previously analysed, were therefore studied.

Subjects and methods

Post-graduate doctors and medical students (n = 5) attending my teaching rounds, medical colleagues (n =
3), nurses (n = 7), hospital ancillary staff (n = 4) and acquaintances (n = 6) were asked if they experienced
headache when they missed sleep. (The numbers in parentheses are those who gave a positive response.) I
then asked for how long they slept normally, how many hours loss of sleep caused a headache, the reasons
for missing sleep, the site and quality of pain and its duration; also which analgesics, if any, were taken, the
speed and degree of response, headaches experienced at other times and whether the family practitioner
had been consulted about these headaches.

Results

Nineteen females and 6 males, aged 25-27 (mean 39) years, normally required 6-10 (mean 71/2) hours of
sleep per day. The characteristics and variations of sleep deprivation headaches are listed in Tables 1-7.
Reasons given for missing sleep were: entertainment (n = 9), reading for pleasure or studying for
examinations (n = 5), working into the night-students needing to earn extra money, nurses on night shift,
doctors on-call, housewives working late at home, or a teacher marking papers (n = 10), sleep

Table 1. Amount of sleep loss causing headaches.

2 consecutive 2-3 consecutive
Sleep loss (h) 1 night nights nights
1-3 4 0 2
2-3 4 7 2
3 or more 4 1 1
 Table 2. Site of headaches.
Forehead 14
Forehead and one or both temples 2
Forehead extending to vertex 2
Vertex 2
One side of forehead; behind eyes;
Right or left side of head; 1 each
Right or both temples; frontal or vertex
or both temples
Deep 13
Superficial 7
Uncertain 5

interrupted by children, noisy neighbours or a heat-wave (n = 4), stress or worry (n = 2), husband waking
early (n = 1), watching television (n = 1), or "just going to bed late" (n = 1). The figures indicate the number of
factors mentioned, some having two causes for sleep reduction. In none was alcohol consumed that could
have been responsible for these headaches; 4 of the 25 had experienced "hangover headaches" (see Table
8).

Only one of the 25 had mentioned this type of headache to her G.P. when consulting him about being
"run-down". The others did not seek a consultation about these headaches; as one volunteer explained,
"there is no point in going to a doctor about something that is your own fault".

Headaches affecting the subjects in addition to those listed in Table 8 were due to travel, bright sunlight,
heat, exercise, neck pain radiating to the head, and an ice-pick headache. The migraines that affected eight
of the group were, on the whole, mild, having ceased in one eleven years earlier at the age of 14; two
subjects had had only three

Table 3. Quality of headaches.

Ache 11
Dull or heavy 8
Pressure 4
Throbbing 3
Discomfort 2
Total 28*
* Three mentioned two sensations.

Table 4. Duration of headaches.

1h 6
All morning 7
Till mid-afternoon 1
All day till sleep 10
Till sleep during the day 2
Uncertain because always took tablets 2
Total 28*
* Three mentioned 1 h or all day.

and five respectively in their whole life and another had one migraine attack a year; one had the visual aura
alone and no ensuing headache.

Discussion

Headaches due to insufficient sleep, regarded as "common", were briefly mentioned by Heyck (1) under the
heading, although distinct from, vasomotor headache. The world's leading authority on sleep-head-ache
relationships, James Dexter, stated in the text and listed in Table 1 of his recent review (2) that sleep
deprivation can cause headache, but he did not specify which type. In the recent headache classification by a
committee of the International Headache Society, sleep loss was listed as a cause of "tension.-type
headache" (3) arising from stress. Black's Medical Dictionary (4) states "headache may be the only symptom
of tiredness". The incidence in the previously mentioned study of more than 38% of healthy undergraduates
(average age 21) cit-

Table 5. Medication taken.

Paracetamol 2 tablets 9
1 tablet 2
Aspirin 2 tablets 5
1 tablet 4
Ibuprofen 1-2 tablets 3
None taken 4
Total 27*
* Two took variable medication (aspirin or paracetamol).
 Table 6. Efficacy of oral analgesics.
Total relief in 20-60 min 13
Partial relief (25-75% reduction)
in 30-60 min 8
No relief 2
No analgesics taken 2

ing sleep loss as provoking some of their headaches needs independent corroboration or refutation.

The response to analgesics in 20 to 60 min in 21/25 of the subjects of this report corresponds to the time
of drug absorption measured by serum levels after oral medi-cation (5). This response contrasts with the
failure of pain relief in tension headaches where patients frequently take analgesic tablets two to four times
daily in spite of deriving no benefit.

Headache is rarely mentioned in the sleep literature. However, in describing the effects of insufficient
sleep for weeks or months, West (6) wrote that patients may complain of "fatigue, musculoskeletal
symptoms, headache, visual disturbances, poor concentration, apathy or depression". In short-term sleep
deprivation a burning sensation in the eyes was common (7) and a general lowering of the pain threshold is
widely accepted (8). However, it has to be stressed that unless a symptom is sought, it may not be
uncovered. For example, headache in the diabetic literature receives scant mention, let alone analysis, yet
Martins and Blau (9) found three different headache types associated with insulin-induced hypoglycaemia in
50 out of 114 patients having such episodes.

How does sleep deprivation cause pain in the forehead? Tiredness results in irritability

Table 7. Number of additional headaches.

Number of Number of
other headaches subjects
0 4
1 14
2 3
3 2
4 2

Table 8. Table of additional headaches.

Alcohol "hangover" headache 4
Hunger headache 4
Sleeping too long 2
Shopping headache 2
Menstrual headache 2
Tension headache 2
Sinus headache 2
Migraine visual aura only 1
classical 1
common 7
Other headaches (1 each) 6 (see text)

and impaired concentration for mental and mechanical tasks (10) and implicates the whole cerebral cortex,
especially the frontal lobes. Although the brain itself is insensitive to painful stimuli, the meninges are
plentifully innervated by nociceptive receptors which, above the tentorium cerebelli, derive from the first
division of the trigeminal nerve, the cutaneous branches of which supply the forehead, vertex and temples.
How brain disturbances induce pain in the meninges, blood vessels or more superficial structures remains
unsolved. It is noteworthy that only three subjects in this series experienced a throbbing headache.

What is the significance of head pain due to inadequate sleep? If pain can act as a warning (11), then
prolonged sleep deprivation should have more profound effects. That is so: volunteers in physiological
experiments or prisoners kept awake for a number of nights develop impaired judgment, become slow in
repetitive tasks, show lack of care in dress and behaviour, become disorientated and even paranoid, deluded
or hallucinated (10)-characteristic of diffuse cortical dysfunction seen in dementia. Furthermore, animals
totally deprived of sleep die after several days ( for review see Karadzic) (12).

A criticism voiced by colleagues is that it is surprising how both too much and too little sleep provoke pain
in the head. However, a range of tolerance is biologically sound, evident in temperature variations, food
intake and serum electrolytes. However, the extremes of these factors result in different responses. Hence
we are led to question the
nature of a 'lie-in headache" which no one has analysed and may differ or resemble sleep deprivation
headache. Research is required. Unsolicited confirmation is always gratifying. Naomi Mitchinson (13), J. S.
Haldane's daughter, in her World War II diaries wrote "constant small chores to do, people to see etc, and
get very very tired. Usually wake with a headache, longing to get one long night. Sleep badly but daren't take
Dial in case I get a hangover".

From the clinical aspect it is important not to label all sleep deprived headaches as psychogenic in origin,
although some undoubtedly are. In this series the majority lost sleep in circumstances when there was no
anxiety or stress, on the contrary many were having an enjoyable time. More fundamentally the function of
sleep remains a frustrating mystery (14), ideas ranging from a restorative function (15) to a "behavioural
survival strategem" (16). If sleep loss causes headaches as frequently as the study on undergraduates
indicates, then assuming that pain indicates a regional disturbance we have a further argument supporting
the notion that sleep, essential to all animals including human beings, has a restorative function (15).

References

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