S3 E2: Sleep and Migraine

A National Migraine Centre Heads Up Podcast transcript

Sleep and Migraine

Series 3, episode 2

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It’s Migraine Awareness Week, and did you know that sleeping too long can trigger a migraine attack? Beware the lie in. Welcome to the Head’s Up podcast brought to you by the National Migraine Centre, the only UK charity treating migraine and headache.


Dr Jessica Briscoe [00:00:25] Hello and welcome to this episode of our Heads Up podcast on Sleep, Migraine and Cluster Headache. I’m Dr Jessica Briscoe and I’ve got Dr. Katy Munro with me.


Dr Katy Munro [00:00:35] Hello.


Dr Jessica Briscoe [00:00:36] And we’re also joined by two other special guests. We’ve got Dr. Alex Nesbitt and Dr. David O’Regan.


Dr David O’Regan [00:00:42] Hello.


Dr Alex Nesbitt [00:00:43] Good morning.


Dr Jessica Briscoe [00:00:44] I think we’ll probably start off by letting you introduce yourselves to our listeners.


Dr Alex Nesbitt [00:00:50] Good morning: Alex Nesbitt. I’m a headache neurologist and sleep doctor at Guy’s & St Thomas’. I work very closely with David, who’s joining us this morning. So I see patients with headache problems and also sleep problems, which I think we’re going to talk more about this morning.


Dr David O’Regan [00:01:10] I’m David O’Regan. I’m a consultant psychiatrist and I work at the Sleep Disorder Centre at Guy’s Hospital with Alex as well.


Dr Katy Munro [00:01:18] That’s wonderful. We’re really delighted to have both of you on this topic today, because Jessica and I were both at a seminar that you gave for the GPs with a special interest in headache. And we all went away extremely inspired. And we know that it’s something that our patients are really often very troubled by. But maybe we can just start off by saying, you know, why do we need to sleep anyway? What is normal sleep? Is there a kind of round up of what we should be thinking that we’re aiming for?


Dr David O’Regan [00:01:51] That’s the million dollar question. Why do we sleep? And I think nobody knows the answer to that. And it’s likely to be multifactorial. So we know when we don’t sleep, then we really don’t have optimal performance the next day. We know it’s important for growth and tissue regeneration, important for our mood and memory. And in 2013, there was a very exciting paper in mice that showed when we sleep, the brain washes itself. It cleans itself of all dirty toxins and proteins that can later lead to Alzheimer’s disease. But when they try to replicate that in humans, the studies didn’t- weren’t really conclusive. So it’s still a mystery about why we sleep.


Dr Katy Munro [00:02:31] Is that the glymph system? Coz I’d heard of that.


Dr David O’Regan [00:02:32] That’s right, glymphatics. That’s it exactly.


Dr Katy Munro [00:02:33] The glymphactic system, ah! So that literally washes your dirty mind clean by the morning. Or at least that’s the theory.


Dr David O’Regan [00:02:42] That’s the theory. That’s it. So the brain is busy cleaning itself at night. Yeah.


Dr Katy Munro [00:02:47] So that’s why you feel groggy in the morning if you’ve had a very bad night’s sleep, because it’s just not peak fitness?


Dr David O’Regan [00:02:55] I don’t think we can blame the glial lymphatics for that. I think there are many other reasons underlying that.


Dr Katy Munro [00:03:02] And what about the length of sleep? So, you know, we hear things about, oh, you should have eight hours and teenagers need more. And Mrs. Thatcher survived on three hours a night. And all of this kind of thing is that all mythology was actually an advised amount of time?


Dr David O’Regan [00:03:19] I think mythology is a great word. So if we start with Margaret Thatcher. So she only really slept for four hours during the Falklands War. Outside of that, she slept a lot longer. And the other famous four hour sleeper was Winston Churchill. But he was a biphasic sleeper. So, yes, he would sleep for four hours at night, but he would have a huge nap, which was really a sleep of three or four hours in the afternoon. So he slept in two phases. And how much we sleep depends on the person and it’s individual to everyone. And you can judge if you’re getting the right amount of sleep for you, if for most of the day, for most days, you have enough energy to do what you want. So the function of sleep is really to serve the day and adults sleep anywhere from 4 to 12 hours. And it’s a normal distribution curve. And I think where the eight hour myth comes from is the study of about a thousand adults where the median was seven point five hours and for publication and media was rounded up to eight.


Dr Jessica Briscoe [00:04:19] Yeah, because I speak to a lot of people who are very fixated on the amount of time they sleep. And also the other thing they are quite fixated on nowadays is those sleep trackers you can get with, sort of, watches. And from my understanding, they’re not- I try and sort of guide people away from getting too fixated. What are your thoughts on sleep tracking?


Dr David O’Regan [00:04:41] So I don’t know about Alex, but I say well done on that. So I act like an old fashioned Irish schoolteacher and I try and take them off them and put them in the drawer in my clinic room so they cause an awful lot of difficulties and they’ve coined a new term. Orthosomnia, the chase for perfect sleep and Fitbit, unfortunately, is one of the devices, to my understanding there’s a class action against them in the States for the misleading information they’ve given, particularly for people with insomnia. Don’t know what you’d say, Alex?


Dr Alex Nesbitt [00:05:11] Yeah, I think that’s right, I mean, the studies show that they just don’t correlate at all to sleep when you look at sleep in a kind of laboratory setting. So these apps that that show you deep sleep and light sleep and people can get very fixated on that and actually, there’s no correlation whatsoever to the sleep staging. I think, probably, their only use really is to tell people what time they’re going to bed and when they’re getting up. And a pen and paper can do just that. So, yeah, I’m with David. It’s a- I’m sure lots of doctors probably feel the same thing when people bring in lots of tracking data as well. It’s kind of helpful, I suppose, but I don’t look at it and I make a point of not looking at it, which sometimes can come across as not the best thing. But actually I think people realise that they can become a bit obsessional about it.


Dr Katy Munro [00:06:07] You could get sleep anxiety from worrying too much about that Fitbit on your wrist saying or you tossed and turned at 2:00 in the morning or whatever and worry unduly. So Fitbits or those kind of things are quite good for seeing whether you’ve done enough steps during the day. But take them off at bedtime as you brush your teeth, maybe?


Dr David O’Regan [00:06:28] Agreed, Katy, totally.


Dr Alex Nesbitt [00:06:30] Absolutely.


Dr Katy Munro [00:06:31] So, Alex, we have a number of patients who we say to them, go and ask your doctor to have a sleep study? So what are the better ways of studying sleep then? I know you can do it at home and I know you can do it in hospital. Can you sort of just speak about the difference between the two ways?


Dr Alex Nesbitt [00:06:48] Sure. So the home studies tend to be geared towards breathing and sleep. So they’re looking at rate and rhythm of breathing. They’re looking at oxygen levels in the blood. So it’s really a screening tool at home and a diagnostic tool depending on the two different types you can do at home. But it’s mainly looking for sleep apnoea. So very useful. It’s useful in headache patients as well who are snorers who have daytime sleepiness. It’s quite a simple test that you can do at home, which will give you usually a good indication of whether or not you have sleep apnoea. So certainly whether or not you have severe sleep apnoea, it might not pick up subtler forms of sleep apnoea, but an easy home test to do, which basically involves just wearing a probe on your finger that measures oxygen levels in the blood, with a little red sensor, a light on it called an oximeter. And some of the more sophisticated devices have belts that you put around your chest and your abdomen, and they can measure sort of depth of breathing and rates of breathing, rhythm of breathing. So it’s telling us whether or not that slowing down in your breathing, pausing and restarting through the night. And it’s those pauses and sort of abrupt restarting of breathing, the apneas that fragment and disrupt sleep and cause you to not be able to sleep as much as you’d like to be able to at night, hence tiredness the next day. And other studies: we use a device that’s similar to a Fitbit, but a bit more sophisticated. So something called Activgraphy, which is a watch. It measures acceleration in different directions. And that can be quite helpful at looking at sleep patterns. So it’s good at looking at the timing of sleep. Doesn’t really tell us a huge amount about the physiology of our sleep, but it tells us quite a lot about the timing of our sleep and how much we’re getting. And looking at patterns like that over weeks can be very helpful.


Dr Jessica Briscoe [00:08:55] I think we’ve touched a little bit on the phases of sleep when were talking about Fitbits and things like that, I don’t think we’ve actually explained what the phases of sleep are. It might be quite useful to sort of go through a bit more of those those basics, if you’re happy to.


Dr David O’Regan [00:09:10] So sleep is highly structured and it’s divided into two main types REM sleep, rapid eye movement sleep or dreaming sleep, and non REM sleep. And non REM sleep is further divided into stages one, two and three. And stage three is slow wave sleep. That’s the most refreshing part of sleep. So at the start of the night, as we transition into sleep, the brain chooses to go down to that stage three slow wave sleep and we get that in the first part of the night. And then as the night goes on, REM sleep or dreaming sleep becomes more predominant.


Dr Katy Munro [00:09:47] And am I right in thinking, I think you gave the example and I heard you talk about this before about the main course of your dinner. And the main course of the dinner was the stage three non REM sleep, and all the rest was kind of aperitifs and starters.


Dr David O’Regan [00:10:03] That’s exactly it.


Dr Katy Munro [00:10:05] I like that concept. So basically, that’s your essential sleep, which your brain is going to drive you into that stage, if you’re very sleep deprived, but all the rest of it is useful too.


Dr David O’Regan [00:10:17] Absolutely so all of the stages are useful, like having a lovely meal with starter, dessert, cheeseboard. But for survival, you really need- and tissue growth and repair. It’s really that main course, that stage three slow wave sleep that you need.


Dr Katy Munro [00:10:31] And the length of those stages changes throughout the night. Is that right? So the length of the phases of sleep rather, is that right?


Dr David O’Regan [00:10:42] We tend to cycle in sort of 90 minute cycles throughout the night. So in adulthood.


Dr Katy Munro [00:10:49] So if you’re woken- if you’re woken up in the middle of that deep restorative sleep, would you feel very different from if you woke from REM sleep?


Dr David O’Regan [00:10:59] You would. And I think most of us have had the experience of this. If we’ve had a nap in the afternoon where we’ve gone into deep sleep and when we’ve woken up maybe for a few minutes, we feel a bit disorientated, our motor coordination might not be that great. We might even have a headache at that time. Whereas when we wake from the lighter stages of sleep, it’s easier to transition out of then. And when we wake from REM sleep, we often have dream recall. We remember what was happening during REM during that time.


Dr Alex Nesbitt [00:11:28] And most of that slow wave sleep, the important sleep is actually, I suppose, a way of looking at it is that the brain discharges all of that slow wave sleep. It gets rid of it, most of it within the first hour, hour and a half of sleep. So that’s where your your brain is really kind of rapidly going into the slow wave sleep. And then it then reduces quite precipitously through the night then. So you’ve got far less of it in the morning. It builds up through the day as well. So if you think- whenever you think about sleep, you’ve got to think about what’s happening during wake as well as a 24 hour cycle. So your pressure to- your brain’s pressure to get rid of this sleep energy is building, building, building, building during the day. It peeks at sleep on set and then it’s rapidly sort of discharged. This what we call slow wave energy. If you think of the brain as being something that’s energetic when you’re sleeping rather than resting, that then all goes within the first hour and a half. So it’s that time that David was saying, if you wake then, then your brain is sort of rapidly discharging all the sleep energy. That’s what you can feel, very, very groggy and very discombobulated.


Dr Katy Munro [00:12:42] So there’s a number of sleep disorders, which I don’t think we’ve got time to go into all of the different ones because we were going to mainly kind of concentrate on the link of headaches and sleep. But I know, you know, some people are suffering from disorders of different phases of sleep and some people just can’t get off to sleep whereas others will wake with broken sleep through the night. And it’s worth them seeking some help for that, if that is troubling them, isn’t it? Do you think people put up with bad sleep a lot of the time or do you think they do come quickly to get help?


Dr David O’Regan [00:13:21] I think they probably suffer in silence for quite a while and there’s usually a crunch event. So something that goes quite bad in their personal or professional lives that then causes them to seek help I think. Sleep medicine isn’t recognised as a speciality in the UK and lots of doctors aren’t trained in sleep medicine. So sometimes a lot of patients will say that they find it very difficult to make it to a sleep clinic or that they felt very misunderstood when they’ve gone to seek help.


Dr Jessica Briscoe [00:13:57] And I do think that’s true, actually. I think it’s probably a very common problem thing in primary care. So people who will describe themselves as bad sleepers and I feel- sometimes feel that it goes on for a lot longer because there is not that much training in it, if I’m honest. And given that it’s a bit like headache, you know, it’s a very common problem people see all the time. And I think it’s seen as people being dismissed. But actually it’s more that some of the basic things that might be useful to teach people about, people don’t have the basics to actually go through that, because there are some things that people can do for being bad sleepers. But also it’s hard to- sometimes very hard to untangle whether sleep is the primary problem or if it’s another disorder they have and how much they tie into each other. I think particularly with things like mental health problems and sleep and headache and sleep as well. I think one of the things that people often want to know about is what can I do for my sleep? What can I- can I take some medication? Is there a tablet that I can take? And it might be quite useful to have a little chat about that, actually. So which medications might be good? Which ones might be bad? Other things that people can do for themselves.


Dr Katy Munro [00:15:11] The sort of self-help things as well are quite interesting, I think people often have tried a bit of herbal this or herbal that, given up coffee and then they come and say, I still I’m still not sleeping. What are the things people can do maybe to even prevent getting into sleep problems?


Dr David O’Regan [00:15:28] So I think it depends which disorder we’re talking about. So if it’s OK, if we go for the most common one, insomnia. So insomnia affects 10 percent of adults in the UK. It’s the most common sleep and most common mental health condition. And there the first recommended treatment is not a medication, but a therapy called cognitive behavioural therapy for insomnia. And there are some very simple techniques that somebody can take from that to try and improve their sleep. The first one ties very well to what Alex said, and it’s a technique called anchoring the day, where you fix a set rising time that you keep seven days a week no matter how badly you’ve slept. And this is quite tricky for the first couple of weeks. But it really changes sleep. It harnesses that homeostatic, that internal sleep drive. A way of looking at it might be every hour that we’re awake we’re collecting sleep fuel and all of us have a sleep fuel tank and my sleep fuel tank is full I fall asleep and all of us will have to be awake for different lengths before our sleep tank fills. And so trying that anchoring the day, trying setting that fixed rising time really, really works. I think the other technique I would put in is something called stimulus control. And often when a person is developing insomnia, they will begin to use their bedroom for lots of other activities to distract themselves for sleep. So they listen to the radio, they might be on their phone, it might be where they go to rest if they have pain or a headache. And over time, the mind forgets that the bedroom is a place for sleep. It now views the bedroom as the rest room, the headache room, the TV room. So in stimulus control, we ask the person to just use their bed and bedroom for sleep, sex and getting dressed. That’s it. And starting with even these very simple behavioural techniques, it can really turn sleep around. And I think the other mistake people make is going to bed too early because it says ten thirty. So I should be in bed at ten thirty or my partner is going to bed at ten thirty, so I should join them. Whereas really we should just go to bed when we’re sleepy, tired. So I might say to patients, when do you go to the fridge and I go to the fridge when I’m hungry. It should be the same with the bed. We don’t open up the fridge door for one hour going still not hungry. Still not hungry. OK, let me get something. So these very simple techniques can really do a lot to help somebody with insomnia. And as you say, Katy, there’s a lot of self-help resources and I’ve given a list that I think you’re going to make available.


Dr Katy Munro [00:18:17] We will. We’ll put some links to that in the blurb. That was a really eye-opening thing for me. Excuse the pun. Hearing you say anchoring the day and get up at the same time, because I think, you know, often we’re thinking, ‘oh, I’ve got to go to bed early because I’m so tired and cram in a bit more early hours of sleep’ and of course it doesn’t work that way. So, yeah, I’ve been finding it very useful. But of course some people will say, ‘well, you know, I have to get up for work at six thirty every morning and then on the weekends I need to catch up’. Does it work? Catching up with sleep?


Dr David O’Regan [00:18:51] It can do in the short term, but if a person is chronically deprived, then they can’t really catch up. And I think if somebody finds themselves lying in for and truly sleeping, not just resting in bed, but truly sleeping for two hours extra at the weekend, then they’re really running short during the week.


Dr Katy Munro [00:19:10] That brings us on to talking about migraine, if we can, because we hear this a lot from our patients that, you know, they’ve got a migraine maybe on the Monday morning. And often when you ask them what their sleep pattern is like, which I and certainly Jess seem to- we often do that. They’ve had a lie in on the Saturday and Sunday and they’ve changed their sleep routine. And then they enter that sort of prodromal phase. And the migraine appears on the Monday and they don’t always link it. So I spent quite a lot of time talking to them about sleep. It’s something to do with circadian rhythms and things like that, Alex .isn’t it, I mean, what is it about the migraine link with sleep?


Dr Alex Nesbitt [00:19:57] If we take that example, if we take the example of Monday mornings, what you’re doing at the weekend is two things, really. So you are staying up later. You are exposing yourself to probably a bit more light in the evenings, you’re pushing your body clock backwards a little bit just from staying up a bit later, night time light exposure. You’re also then sleeping in longer. You’re having your lie in. So the sleep tank, that energy that’s building up through the day, you’re altering the dynamics of that, your sleep fuel is reduced. It’s not sort of rising at the rate you’d want it to. You’re then going to automatically go to bed or feel tired later on the Sunday night. You’re then going to restrict your sleep quite significantly on Sunday night. You may also have worry about work and you might be ruminating about various things. So you’re altering three things. You’re altering your body clock to a small degree, you know, not to huge degrees, but you’re altering the timing of your body clock. You’re altering the duration of your sleep. And you’re also kind of altering this relationship between the build up of sleep energy and then it’s dissipation through the night. So there are three factors there that I think can just throw the brain ultimately. We know that migraineurs need consistency and they like routine and a migraine brain kind of- the environment for a migraine to best be triggered is when that routine goes off balance. So when you skip meals, when your sleeps fragmented, when suddenly stress is relieved, you finished an exam or the first day of your holiday. So instinctively, we’re kind of doing these three things at the weekend. We’re doing them on Saturday and Sunday and altering that consistency in that routine, which builds up a bit of a perfect storm on a Monday. You might also feel particularly tired on Monday morning and skip breakfast to get to work on time and it’s cumulative. The more of these small changes that you’ve made, I think, make the migraine more likely to happen.


Dr Katy Munro [00:22:08] I suppose the other thing, especially before lockdown, was people might have gone out on a Friday or Saturday night and had more alcohol than they have during the week and maybe had a couple more cups of coffee on a Saturday morning to get them up and going. What’s the role of alcohol and caffeine in our sleep patterns?


Dr David O’Regan [00:22:29] So alcohol is a double edged sword. It’s brilliant at getting somebody into sleep, but then it leads to a very fragmented night, a very broken sleep and a sleep that’s of shorter length than the person would normally have. So I would really try and encourage somebody to try and avoid drinking, at least, at the very least in the two hours before bed. And it’s surprising even people who might just have a small glass of wine or a single gin and tonic that can be enough to upset their sleep. Caffeine then sort of blocks the sleep fuel. So if you’ve gone to the trouble of anchoring your day and you’re collecting that sleep fuel beautifully, then caffeine will block that. And caffeine hangs around in the body for a long time. So it can be up to ten or twelve hours in some people. So meaning if you have a coffee at 12:00 noon, then half of that cup might still be circulating in your system by midnight, which is alerting. And for somebody who might drink more than five cups of coffee a day, then caffeine reaches a steady state in their bloodstream and that will adversely affect their sleep as well. So generally, our advice for caffeine is none after 2 p.m. which seems to work well for most people.


Dr Katy Munro [00:23:46] Yeah, that’s what I advise people. And I think there’s also some evidence if you drink that much coffee every day, five cups a day, you can get chronic headache from having caffeine overuse as well. So we’re always saying pull the caffeine early, change to decaf at lunch time. And people sometimes say, ‘well, it doesn’t affect me, it’s fine’. But I guess, you know, some people do manage to tolerate it. But it’s not a good idea if you’re having any disruption of your sleep.


Dr David O’Regan [00:24:15] And I think that’s a great point, Katy, because lots of people with insomnia might be told to cut out coffee and cutting out coffee on its own won’t fix an insomnia, but it’ll make the other techniques easier. So I think that’s a more helpful way for patients to maybe look at it.


Dr Jessica Briscoe [00:24:33] Yeah, and I think also I tend to think of people, with regards to caffeine and headache, people say, ‘well, I try to not have caffeine, but then I get a headache because of that’. And I do find that sometimes people- actually that withdrawal headache is a bit of a sign that you’re probably having a bit too much caffeine. And sometimes I do tell people to sort of just go down on it a bit more slowly before cutting it out.


Dr Katy Munro [00:25:04] Sometimes people with migraine, we find an awful lot of people say, ‘well, I wake up in the night with a migraine attack, it wakes me at say, four or five o’clock’, is that something that- is there an explanation for why that happens?


Dr Alex Nesbitt [00:25:20] Yeah, it’s interesting. It’s surprisingly common. And I think also we don’t tend to ask too much about when the attacks start, but I think it’s surprisingly common. So there’s no real study that’s shown what the exact link is but if you think again about the brain being in this very energetic state, going between slow wave sleep and rapid eye movement sleep, it’s changing. So it’s shifting every 90 minutes. It’s changing between these different levels. And that also has an effect on the part of the nervous system, the autonomic nervous system that’s involved in heart rates and blood pressure regulation, various other things. And I think having those- having fairly rapidly changing fluxes in these systems again creates quite a good storm, if you like, or a good environment for thresholds for migraine to be lowered and for the attacks to be triggered. So I think it’s about the changes in brain state when we’re asleep together with the timing of our sleep. So I think that’s a sort of vulnerable window within a twenty four hour period, if you like, where our thresholds lower for migraine. And then on top of that, you have these changing systems, brain systems that are making it much more likely that an attack will be triggered. Of course, we don’t know. So people with migraine with Aura may well be sleeping through their aura phase and then waking up with the headache. I think that’s probably fairly common as well. So you’re right, it tends to be around the kind of three, four o’clock in the morning people will wake with this feeling of discomfort, and often they will then maybe go back to sleep. And by the time they wake up properly in the morning, then it’s really established. And we’ve lost that window for treatment as well, I think, you know.


Dr Katy Munro [00:27:20] So the other thing that some people say is that they can only get rid of their migraine if they take their medication and then go to sleep.


Dr Alex Nesbitt [00:27:29] Yeah.


Dr Katy Munro [00:27:29] Whereas speaking personally, if I have a migraine it gets worse when I go to sleep. So I can’t- I can’t sleep it off. And yet some people seem to be able to sleep it off and have to, in fact.


Dr Alex Nesbitt [00:27:42] So there are also things there. It’s interesting, I think so children typically will need to sleep to terminate their migraine attack and sleep or vomit. That’s the other thing. So a lot of people will say that when they vomit, actually, that’s when the migraine stops. And I think that it’s so if you think of sleep and going into sleep again, the autonomic nervous system, this bit of the brain starts to change very rapidly when you go into sleep. So I think it’s that mechanism that’s probably helpful, that has some effect on toning down the migraine and potentially even stopping the migraine in the same way when you vomit, there are all these big changes in the autonomic nervous system. So I think it’s that sort of abrupt switch that can be helpful in some people at stopping the attack. There are also a group of patients with migraine whose sleep I think is part of their attacks. So we have these rare, as you know, these rare migraine disorders, migraine with brainstem aura where actually you can get an overwhelming urge to need to sleep. And I think sometimes that can be part of the aura itself. So people may say, ‘well, I just have to go to bed’ and it’s difficult to know whether or not that’s their brain forcing them to sleep or if they’re doing it habitually to try and, you know, treat the attack.


Dr Jessica Briscoe [00:29:02] I did wonder about behaviour actually as part of it, because one of the questions I had was I’ve spoken to a lot of people recently who will say that sleep after migraine is problematic. And I wonder- I’m sort of wondering about napping and sleeping in the day whether it was problematic people with migraine anyway. But if people are having attacks, then going to sleep afterwards in the day, then sometimes they find it much more difficult to sleep at night. And I wonder if that feeds into the attacks.


Dr Alex Nesbitt [00:29:31] Absolutely. And I think when that’s happening frequently enough, then that’s when you do start to set up or you become at higher risk of developing insomnia, then there becomes a bit of a vicious circle. Insomnia becomes a risk factor for then potentially having chronic migraine. It sort of goes around in a bit of a loop. So that’s right. I think it’s difficult because it differs from individuals to individual- amongst individuals. But I think if you feel that the nap is a sort of habitual thing to do after an attack, that’s probably better avoided certainly in the afternoon and evening. That would be better avoided, because you are then going to start setting yourself up for poorer sleep the following night. I mean, if people are having in frequent attacks, it’s probably fine. But you know if they’re having an attack a couple of times a week, then you really do- you can see how, again, this sort of perfect storm for developing insomnia starts to develop. And you may also- patients may be taking medications that make that worse. So we know none of us like prescribing opioid medications for headache, but we know that opioids contribute to insomnia as well. So it can be very, very tricky. So I would say if the nap is becoming a habitual way of dealing with the headache, then I think we just need to keep tabs on the naps, probably.


Dr Katy Munro [00:31:00] One of the medications that we frequently use as a preventer for migraine is amitriptyline. And sometimes patients come back and say that really helped me sleep. Sometimes they come back and they say, that made me so sleepy I couldn’t wake up the whole of the next day. And it’s an illustration of how individual the plan has to be for each patient. We say to people, we can’t. We have to see you and speak to you and kind of work out what is the best way for you, because there isn’t one way that fixes everybody with migraine. And what do you feel about- how do you feel about amitriptyline as a sleep inducer?


Dr David O’Regan [00:31:45] So in the context of insomnia, without headache, where it’s not prescribed for pain or headache. It’s something that I see primary care colleagues using a lot. And it’s without an evidence base. And it’s not a medication that I ever prescribe. I find that tolerance builds very quickly when amitriptyline is used for sleep. And because of its anticholinergic effects, there are just better hypnotics to use. So it’s not something that I use. It will also worsen restless leg syndrome if somebody has a tendency towards that. And any hypnotic any medicine used for sleep, they’re not general anaesthetics. If you don’t have the structure right around the principles of cognitive behavioural therapy for insomnia, then the hypnotic will have no chance of working.


[00:32:40] So can you say a bit more about restless leg syndrome? Because I’ve definitely got patients who get that as well. Sometimes they don’t even mention it unless you specifically ask they just move their legs a lot when they are going off to sleep.


Dr David O’Regan [00:32:53] I think that’s a great point. Katy. So I think when you tell somebody in a clinic ‘oh you’ve got restless leg syndrome’, they say ‘is that a thing? I didn’t know I’ve had that for 20 years. My mother had it, my grandmother had it.’ That’s it. And so it’s this uncomfortable sensation deep in the muscles, usually in the legs that comes on in the evening that’s associated with an urge to move and movement gives temporary relief. And the minute the person has a puzzled face, when they’re trying to find the adjective to describe the sensation, I think, you know you’re onto a winner.


Dr Alex Nesbitt [00:33:27] I agree that’s the clear marker.


Dr David O’Regan [00:33:27] And people have said it’s like tingling or creepy crawlies in my legs or electricity or there’s an energy in my legs. It’s amazing the descriptions people give us in clinic.


Dr Alex Nesbitt [00:33:38] But there’s still even with that, there’s still not the right word is that they’ll say, ‘well, it’s not a pain it’s not really that- it’s not electricity. It’s not really a sort of numbness.’ We have English being such an expressive language we do not have the right word for that sensation. And if you’ve had it, you’ll know exactly what that sensation is and it’s just impossible to describe.


Dr Katy Munro [00:34:01] How long does it go on for the restlessness? Does it go on for an hour and then you go off to sleep or does it go on for the whole night?


Dr Alex Nesbitt [00:34:07] It varies from individual, but there is definitely a daytime pattern to it. So one of the markers of restless leg syndrome is that it will start to emerge in the evening hours and then build before sleep onset and then stop people getting off to sleep. Typically after a few hours of sleep if they’re waking up, they may not have it then some people are unlucky enough to still have it when they wake up in the night. But by morning it’s gone. So in people with fairly standard restless leg syndrome, the kind of the common type that might not get some medical attention, that sensation will not be there in the morning, but they may also experience it so if their legs or in a sort of confined space. So a typical example would be if they’re at the cinema in the evening. So past nine o’clock, can’t move their legs, start to get a little bit sort of uncomfortable bit fidgety need to stretch out their legs. So there’s very much this circadian, this daily build up through the evening, which peaks at around sleep on set, which is why it can cause insomnia sometimes and then and then and then goes away by morning.


Dr Jessica Briscoe [00:35:21] Is there actually an association between restless leg syndrome and migraine because I remember I went through a stage where I felt like everybody I saw in clinic had it. And people do ask the question, has any link been clear?


Dr Alex Nesbitt [00:35:33] Yeah. So certainly there are big studies that have been done in Scandinavia. It’s a big population based studies which ask people fairly simple questions about headache. So there’s certainly an association between headache and restless leg syndrome. So you’re more likely to have restless leg syndrome if you suffer with headache, and that likelihood increases if you have more chronic headache. They didn’t necessarily look at the different types of headache, and if we assume migraine being the common headache, then I think we can extrapolate from that. So, yes, there’s also some scientific work that has found an area of the brain in the hypothalamus that is involved in both migraine pathology and also restless legs pathology so there is some scientific evidence to back up those observations as well.


Dr Katy Munro [00:36:25] And it can be helped can’t it. It’s worth people not putting up with it and going and asking their GP or asking for a referral to a sleep clinic to get some advice? Is that what you would advise people to do? Are there are some simple things we can do? Are there any supplements or anything like that make a difference or is it medication?


Dr David O’Regan [00:36:44] So we don’t really know what causes restless leg syndrome. There’s one hypothesis that it’s related to iron levels. And so one thing somebody can do is check their iron and their ferritin levels. And the American Academy of Sleep Medicine would recommend a higher than normal ferritin level for somebody who had a restless leg syndrome. So that’s definitely worth doing. Often it’s with other disease states like low vitamin B 12 or thyroid dysfunction. So really having good baseline blood tests, including ferritin and Iron is well worth trying. Other simple things are caffeine exacerbates it as does nicotine as well alcohol. So trying to avoid those, like we said earlier, and lots of people get relief from being in water. So having a bath sort of two hours before bed, some people get relief having massage at that time. And there’s a small evidence base for magnesium citrate as an over-the-counter supplement. But if those simple steps really weren’t helping, then it’s well worth seeing a specialist.


Dr Katy Munro [00:37:48] I wondered about magnesium because we know that there’s an evidence base for preventing migraine. If you take magnesium citrate in high doses and Jess and I have done a podcast episode talking about different supplements with evidence base, but I’ve also in the past had an interest in fibromyalgia and people often seem to benefit from magnesium, either in tablet form or sometimes even putting Epsom salts in the bath and magnesium sulphate soaks. And so I wondered if there’s any evidence, but sometimes it’s just there aren’t any studies on those things.


Dr David O’Regan [00:38:22] I agree with that. And I’m not aware of any study that uses Epsom salts in the bath, but lots of patients will say that’s their preferred way of being exposed to magnesium. And that really helps so if it helps, brilliant.


Dr Katy Munro [00:38:35] Very safe.


Dr Alex Nesbitt [00:38:36] But I think iron is the way forward I think as the main sort of supplement, the main check, it would be iron. And even if your iron levels, as David was saying, were normal or on the lower side of normal, just sometimes boosting that with iron supplements or prescribed iron can be enough.


Dr Katy Munro [00:38:56] I was saying to somebody the other day that the range of normal for ferritin is the range of normal for men and women. And we know that women actually feel better if they have a higher ferritin anyway. They don’t get so much fatigue, they don’t get so much hair loss and things like that. So I think we need to be careful about what gender the patients are as well when we’re looking at normal ranges don’t we?


Dr David O’Regan [00:39:19] Yeah, I agree.


Dr Jessica Briscoe [00:39:22] Cool. Maybe we could talk a little bit about cluster headache as well I’m just thinking about the fact that this is a- a lot of people find that their their attacks happen at night. And there’s a bit of, having talked about circadian rhythm, cluster headache has a periodicity, it’s not always circadian, but is there a link between sleep and cluster headache?


Dr Alex Nesbitt [00:39:46] Certainly it’s highly likely to happen at night time. About 70 percent of people with cluster headache, certainly in the first few bouts, and people who have the episodic form of the disorder will have their major attack arising from sleep. A major attack typically would arise from the first sleep cycle or shortly thereafter. So within maybe 60 to 120 minutes of sleep onset and the thing that people will tell you is that it seems to happen, the phenomenon is that it happens at the same time every night. So, you know, you can almost set an alarm clock by it. So that’s a unique element of the biology of this disorder that we don’t fully understand yet. But I think my hunch is that it’s related again to these shifts in the autonomic nervous system that are happening during sleep. So the brain is switching between states, between sleep states and sleep stages, and that’s also having an impact on the autonomic nervous system. So I think it’s a switching mechanism that seems to be linked to sleep that’s triggering the attacks. They used to say that cluster headache arose from rapid eye movement sleep or REM sleep. But actually, the more modern studies have shown that that isn’t the case. So it’s not quite as simple as that. Whether or not that is due solely to sleep or if it’s due to the body clock, again, is an area of debate. So we know that if you sleep during the daytime with cluster headache, you can have an attack that arises from a daytime nap. So that might suggest that actually it’s the sleep mechanism is more important maybe than the circadian mechanism or do the two have to be in alignment. So does it have to be the right time in the 24 hour period with sleep on top to kind of increase the probability of an attack happening? Or can you separate them? And that’s a very difficult thing to say. The reason I think people became interested in circadian rhythms is the timing of these attacks and also the fact that melatonin levels seem to be reduced in people who have cluster headache, whether or not that’s because of the cluster headache disease, because of the biology of it, or whether or not that’s because pain suppresses the melatonin secretion by the brain, we don’t know for sure. But it’s yeah, there’s clearly something in this. There’s clearly something in the timing and the sleep relationship to cluster headache that gives us a clue about its biology that we’ve been looking for. Haven’t quite found the answer yet, but it’s going to take a bit more work. But I think it’s there’s certainly something in it.


Dr Katy Munro [00:42:44] Melatonin is a really interesting one. I know in this country it’s only licenced for use in over 55s  with insomnia. But I know some of the guidelines suggest using really quite high doses of melatonin for cluster headache, up to 10 or 12 milligrams instead of the usual 2 milligrams. Is that right? Does that work for some people?


Dr Alex Nesbitt [00:43:05] That’s right. Again, the evidence is fairly limited. There are a couple of clinical trials which suggest that a high dose of melatonin, in episodic cluster headache can be useful up to 15 milligrams. The trials were small and it was difficult to say whether or not people were just coming to the end of their bout or whether or not it was the therapeutic effects of the melatonin. We do use it and I have seen success. And again, it seems to be at higher doses, so up to 15 milligrams. But usually we’d be using it as an adjunct, so we’d be adding it in to another medication. So on top of say verapamil or topiramate, it would be used and can be helpful. It’s not it’s not the panacea that it, you know, perhaps was thought to be. But it can be helpful. It’s not going to do any harm either. So people even even with pretty high doses of melatonin, don’t tend to get much in the way of side effects.


Dr Katy Munro [00:44:05] You wouldn’t expect a GP to be prescribing that sort of high level without having some pointer or guidance from a specialist in headaches, would you? I think a lot of GPs might baulk at the prospect of initiating that sort of dose without somebody who sees a lot of cluster headache patients suggesting that.


Dr Alex Nesbitt [00:44:27] I think that’s right. And I think if I use it, I would typically initiate it and then have a discussion with the GP and see if it’s effective. So I think we know fairly quickly within a couple of months whether or not it’s going to be something worth pursuing.


Dr Katy Munro [00:44:44] I also just wanted to ask about high doses of caffeine. So I’m on a forum of cluster headache sufferers in the UK and a lot of them use the high caffeine drinks like Monster Drinks or Red Bull because of the taurine in these drinks. And they seem to find in some people that that’s really helpful. Can you say anything about that?


Dr Alex Nesbitt [00:45:11] Yeah, it’s certainly something that people have described. It’s not been systematically studied in any way, to my knowledge. I wondered once at one time when i started thinking about this, if it was the- if it was other things. But it does tend you’re right. It tends to be something to do with the caffeine in the taurine. I wondered, people also say it’s got to be quite cold. I don’t know if they say that on the forums as well.


Dr Katy Munro [00:45:34] Yes.


Dr Alex Nesbitt [00:45:34] So we’re sort of taking a cold can of one of these energy drinks and really glugging it. Not sort of sipping it, but really sort of knocking it back. Yeah, shotting it. The same thing with the sort of hot double espresso. So I also wondered whether or not there might be some sort of reflex going on there with temperature control, but it could well just be the taurine. But it seems to happen quite rapidly. It’s quite helpful rapidly when people describe that. So, you know, it’s probably going to take a while for all of that- the taurine and the caffeine to be taken up by your system, whereas the effect seems to be a lot more rapid than that. So my assumption and this could be wrong, is that it’s probably the act of glugging and the temperature that might be doing something maybe.


Dr Jessica Briscoe [00:46:22] I was going to ask a bit more about the melatonin just because it’s more about the formulation and the fact that a lot of people do try and get melatonin sort of maybe from health food shops or from other countries where you can buy over the counter. And it will come in, I’ve looked at these they’re quite confusing, I think, for people. Is it better off being prescribed one? And does the does the release, so if it’s a slow release formulation, does that make a difference or would you prefer it fast release, is that known?


Dr Alex Nesbitt [00:46:57] It’s not known. And we may often try both. We may often try and sort of bio melatonin, which is the more immediate release form, which is harder to get hold of, much harder. And you often need special funding agreements and the patients need to try and source it themselves. Sometimes if it’s easy enough to prescribe we’ll use the controlled release. We don’t know is the short answer. I think people have to be very careful when they’re buying melatonin supplements online, huge differences in dosing, huge differences in quality. I think one study did look at how much melatonin is actually in one of these kind of sort of over-the-counter pills that you can get in the US and various things versus what is claimed on the packet. And there’s huge variability. So it is difficult. It’s difficult. I prefer to prescribe it and I would initiate the controlled release form first and see whether or not that’s helpful. If it’s not, we either draw a line under it or if there are very few other options, with cluster headache, then I might try the bio melatonin, the immediate release version, which again is very difficult to get hold of but not impossible.


Dr Katy Munro [00:48:16] Can we talk a little bit about- moving on to a subject of obstructive sleep apnoea? So we have had a number of patients who’ve come in with chronic headaches and who when you ask them, they say, ‘well, yes, my partner says I really snore badly. And I scare them because they think I’ve stopped breathing and I wake up with a start’. And they often haven’t even thought about this condition. And we send them off for a sleep study. And I’ve certainly had a couple of patients who come back and said, ‘oh, I did have it and I’m on the CPAP’. And yeah, some of them get better and some of them the headaches don’t get better, but is that a known cause of headache?


Dr David O’Regan [00:49:01] Yeah, so Morning Headache is a recognised symptom of obstructive sleep apnoea. So along with that loud, anti-social snoring that you described, Katy. Needing to get up and urinate quite frequently in the night, waking with that sandpaper, dry mouth in the morning and morning headache for some patients, so well recognised as a symptom of obstructive sleep apnoea and well worth investigating like you’re doing with your patients.


Dr Alex Nesbitt [00:49:27] And classically, that sleep apnoea headache will be a fairly featureless headache. So it will be there on waking. It will go within an hour or two, usually of its own accord. There won’t really be the nausea and the sensory phobias associated with migraine there. And people can have both. So I do think it’s always worth, even if it sounds more like somebody has chronic migraine than sleep apnoea associated headache, you can reduce the burden of the chronic migraine by just taking away the additional sleep apnoea headache. Even though you may have to do some further work to treat the chronic migraine, you can still ease the burden if there is sleep apnoea there. It’s also interesting in people who have very high frequency of episodic migraine, so not daily, but several times a week, if sleep apnoea is present then treating the sleep apnoea, might stop conversion of the episodic migraines and more of a chronic migraine. So absolutely worth asking people about. And migraine sufferers were thinking about whether or not they snore, if they’re feeling tired during the day, it’s just getting up at night to pee. As David says, that dry mouth in the morning, all these little markers would push me towards sending somebody for those sleep studies that you’re doing.


Dr Katy Munro [00:50:47] Yeah, there’s quite a long waiting list though. There is not enough of you.


Dr Alex Nesbitt [00:50:54] Yeah there is. Well, I think there’s probably also, with the COVID situations, I suppose in a way easing this to some extent that we are putting much more of the diagnostics out into the community now. So people are being sent home testing kits that can screen for sleep apnoea. So I think we’ll see more of that over the next few years. So actually doing that almost before you come see a sleep doctor is a sensible thing to do because you already have that information. So hopefully those waits will reduce.


Dr Jessica Briscoe [00:51:25] And I would say from a GP point of view, I think sometimes GPs have found it traditionally quite hard to know whether to refer because they’ve used the Epworth sleepiness scale. And I’ve certainly seen patients that have clear obstructive sleep apnoea that don’t necessarily score in the range that you have to get to refer. Are there better ways for GPs to assess this?


Dr David O’Regan [00:51:47] There’s another scale called the stop bang scale? And this is readily available and it’s computerised. So through simple Google search, you’ll find it and it’s a much more objective measure and it gives you a risk index at the end about how likely is obstructive sleep apnoea in this person. So it’s a very quick- takes less than a minute to do. It could be used as well.


Dr Alex Nesbitt [00:52:13] And you can’t forget that name, can you? Stop Bang.


Dr Katy Munro [00:52:20] The other one that we wanted to ask you about, Alex was hypnic headache. So I, I understood that this was one that sort of comes on often in women over the age of 50 ish and wakes them consistently at the same time each night and then gets better, again a featureless headache and and goes off as the day goes on, as they get up and move around. But you put doubt in my mind when I last heard you speak saying that you think this might just be a feature of migraine.


Dr Alex Nesbitt [00:52:52] I think I should clarify. So I think for me, somebody who loves sleep and headache, it’s the sort of it’s the unicorn. It’s the mythical beast for me. But I do think it exists. I do think that there are pure forms of hypnic headache. I think it’s probably overdiagnosed and we’re actually seeing migraine. This, as Jess was saying, this kind of waking up at 3:00 or 4:00 in the morning with a migraine attack. The pure hypnic headache, I think, is the thing. And certainly the person that you’ve just described, the woman who might be over 50, who’s waking at the same time with this featureless headache, we do see that. There’s usually a bit of a history of migraine in the background perhaps. It can be very difficult to tease it apart. Some of the more recent studies looking at hypnic headache suggest that actually some people do have a bit of nausea. They might have a little bit of a sensory phobia, not to the sort of migraine scales, but some of those features are also active in hypnic headache. I think one way that I find it quite useful to look at the three types of headache that will wake you in the night routinely, so there’s cluster, which we talked about. That throws you out of bed. So you are thrown out of bed with a cluster headache and you’re on the floor. You’re rolling about, you’re pacing about, you’re hitting your head. You are active. Hypnic headache might compel you to sort of sit up and it might make you want to walk to the bathroom or go and get a glass of water or just sort of not in a ‘distract myself’ kind of way. But you may want to move, whereas migraine, I think you’re just going to want to lie there and keep still. So I think if people are waking with a headache and they’re getting up and pottering, that was quite a strong sort of marker for me of hypnic headache. I thought when I started this job that I’d have lots and lots of patients with hypnic headache, but I don’t. So maybe that’s part of my bias as well. But it’s certainly an interesting phenomenon.


Dr Katy Munro [00:55:07] That’s really helpful actually. The difference between the movement, we certainly already see that with cluster headache and migraine patients, I sometimes say to patients who are struggling to get a diagnosis of cluster headache, take a video, get somebody else to take a video of yourself because you see them sort of thrashing around and banging their heads. It’s very, very typical of a cluster headache where people have migraine. I know this myself. I just want to stay really, really still. So, yeah, that’s really useful.


Dr Jessica Briscoe [00:55:40]  There was a couple of other things I wanted to cover just because we mentioned the importance of generally managing sleep. I kind of want to do a bit of a plead to not go straight on medication and the reasons why, because I think we probably all share a hatred for Z drugs generally. And I see a lot of people with migraine or headache or generally who say ‘the only thing that I can do, just give me the tablets, give me this’. And I sort of I know that I often say to them, it doesn’t make you sleep well. But is that a- is it established that it’s actually not giving you a good quality of sleep, but it’s just sort of helping people to knock themselves out a bit more. Or am I just telling people nonsense?


Dr David O’Regan [00:56:25] So with the Z drugs as zolpidem and zopiclone in the UK. We’re stuck in quite a difficult position because the licencing guidelines would tell us that we can just give for a maximum of four weeks. And that’s very difficult. And as you rightly say, for some patients, it is the only medication that might be helpful. So I think lots of sleep physicians definitely break the rules. And I certainly have patients on zopiclone for years who have no evidence of tolerance or dependency. And it truly is the only thing that works. I think the thing I do- which I think you’re alluding to as well, Jess, is every time I might prescribe then I’m prescribing CBTi, cognitive behavioural therapy for insomnia, in tandem, because what we know is that once you stop a hypnotic, it’s controlled the symptoms of the insomnia, it hasn’t cured it. Insomnia will come back, whereas cognitive behavioural therapy for insomnia is the only cure, the only proven cure, and doing both in combination sometimes the Z drug will give immediate relief and sometimes you need that. If a person is about to enter a depressive episode or is in one or is about to lose their job or their relationship, you have to act quickly, whereas the CBTi will take time to work. So take sort of that pragmatic approach with them I think yeah.


Dr Jessica Briscoe [00:57:51] I think it’s more of a plea of a ‘don’t just medicate it’, which is what we’re always saying in headache medicine anyway. You know, you’ve got to look at everything around it. But I think it’s particularly true with sleep so that was the main thing I wanted to bring up.


Dr Katy Munro [00:58:04] Just a word about shifts. So we have quite a number of patients who have to do shifts, maybe healthcare professionals or people who work in transport or in factories and things. Any guidance about how we help those with their sleep patterns. Is there any where they can go to get advice maybe on your list of resources, David?


Dr Alex Nesbitt [00:58:29] It’s actually a very difficult- it’s a very difficult situation because shift patterns vary so much. So big employers tend to have as best, sort of, practise with designing rotas so that shifts will follow a pattern whereby you’ll start with an early and then days, then evenings, then nights. So there’s sort of a clockwise pattern rather than a random pattern. So there’s some evidence to suggest that that’s better. So if people have the fortune of working for employers that have put that into place, that’s helpful. Trying to just keep up enough sleep I think is the key thing. And it’s very difficult to sleep during the daytime. Some people struggle with that. So trying to get enough opportunity to sleep is difficult. So seeing if there are ways to increase that opportunity to reduce distractions. All of those sort of self-help measures can be useful. Occasionally using a tiny little bit of melatonin or something like that. If you’re if you’re coming off the night shift and you need to sleep during the day, that’s when using melatonin as a sleeping drug is very helpful. So melatonin is much more effective as a sleep medicine if you’re using it to sleep out of your normal phase. So for jet lag or for shift work than it is if I was just going to take it tonight to help me to sleep during my normal sleep phase so that can also be helpful. Nightshifts and surviving night shifts again, I think migraineurs will say ‘it’s very difficult to stay awake. I’ll start to get a headache in the early hours of the morning’. If you have several night shifts in a row then what I sometimes suggest to people is having a nap, having a sleep before you start your night shift can be quite useful. So that sort of reduces the build up of that sleep energy through the nights, which can be helpful. The other thing is using caffeine almost as a prevention at night time. So don’t wait until your eyes are really kind of dropping and drooping and you can’t stay awake and then go and get a coffee actually, you know, maybe use caffeine, if you’re going to use it, use it before you hit that stage. And regular breaks, you know, having regular breaks and pacing yourself through the night and also trying, it’s very difficult because some people rely on night shifts and that’s their entire livelihood, but trying to minimise the number of night shifts and have enough off days and that sort of thing. Prepare for your night shifts can be helpful. So consistency and routine as much as possible.


Dr Katy Munro [01:01:17] There is a BMJ infographic page. If any doctors are listening and we do have some doctors who listen. So if you go into the BMJ website and type in infographics, there is a really helpful infographic there about shiftwork and trying to optimise shift for doctors who are having to do that. Sorry Jess, you and I keep clashing.


Dr Jessica Briscoe [01:01:36] I know. I think we both pause and then we sort of talk at the same time. This is the problem with not being in the same room. No, I was going to say, I certainly remember that one of my big reasons for not doing any jobs that had shifts was because I used to get migraines usually when I was switching back from nights to days. And doctors often do these very strange shift patterns anyway. Do 3 and then you’ll do a week at some point. And I remember that being a massive issue. So I sort of wish I’d had some of that advice when I was doing my night shifts years ago.


Dr Katy Munro [01:02:09] I think we’ve probably covered most of the points that we wanted to. Are there any other key messages that you guys would like us to send out there to the listeners about sleep. David, would you like to go first?


Dr David O’Regan [01:02:23] So if you’re experiencing sleep difficulties, you’re not alone, that you have plenty of other people because it can be often very lonely and there are lots of adults in the UK are experiencing sleep difficulties. And there is lots of help out there. So don’t be shy, ask for help. And if you don’t get it the first time, ask again. The help is definitely there.


Dr Katy Munro [01:02:46] Excellent. Alex?


Dr Alex Nesbitt [01:02:48] Yeah, I think particularly for people who suffer with headache then trying to- I know it’s easy to say hard to do, but trying to keep as much consistency and routine with sleep as you can is going to be more helpful in the long run. And I think the key thing would be your anchor- your morning anchor that David spoke about and getting up at that same time each day, even if you had a lousy night. Trying where you can to do that, I think is probably the most helpful thing you can do in the long run, even though I appreciate entirely that it’s not always easy.


Dr Jessica Briscoe [01:03:26] Yeah, wonderful. Well, thank you both so much for joining us today. I think our listeners will find that really, really useful. And hopefully some of the medical professionals who listen to you will be able to learn a bit more of the- hopefully some of that more lifestyle, all those sort of sleep anchors and things like that to sort of help their practise as well. Thank you very much.


Dr Alex Nesbitt [01:03:49] Thank you.


Dr David O’Regan [01:03:50] Thank you.


Dr Katy Munro [01:03:53] Thanks for listening to our podcast on sleep and its relationship with headaches. This is Migraine Awareness Week and we’ll be doing a lot of posts on social media about further topics to do with self care and migraine. Tune in a fortnight for our next episode of the podcast. Thank you.


[01:04:14] You’ve been listening to the Heads Up podcast. If you want more information or have any comments. Email us on info@NationalMigraineCentre.org.uk. Till next time.

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