Margaret Park

Chronic headaches and insomnia: Working toward a biobehavioral model

Background: Sleep disturbances are consistently associated with chronic headaches, yet the mechanisms underlying this relationship remain unclear. One potential barrier to generating new hypotheses is the lack of synthesis between models of headache and models of sleep. The goal of this paper is to present a perspective on the chronification of migraine and tension-type headaches based upon conceptual models used in sleep research. Methods: We provide a critical review of the literature on sleep and headache, highlighting the limitations in sleep methodology. Models of sleep physiology and insomnia are discussed, along with the potential implications for the chronification of migraine and tension-type headache. In addition, we propose a biobehavioral model that describes the interaction between behaviors related to coping with headache, the impact of these behaviors on insomnia and sleep physiology and the downstream propensity for future headache attacks. Conclusions: We hope that this perspective will stimulate interdisciplinary activity toward uncovering the pathway for more effective interventions for chronic headache patients.

Sleep Complaints and Incident Disability in a Community-Based Cohort Study of Older Persons

OBJECTIVE Sleep complaints are associated with adverse health consequences. We hypothesized that non-disabled older persons with more sleep complaints have an increased risk of developing disability. METHODS Subjects included 908 older clergy participating in the Religious Order Study without clinical dementia, history of stroke, or Parkinson disease. At baseline, participants rated their difficulty falling asleep, frequency of nocturnal awakenings, sleep efficacy, and napping frequency, from which a summary dyssomnia measure was derived. Self-report assessment of disability included instrumental activities of daily living (IADLs), basic activities of daily living (ADLs), and Rosow-Breslau mobility disability at baseline and at annual evaluations. RESULTS Mean follow-up was 9.6 (SD: 4.2) years. At baseline, more than 60% had one or more sleep complaints. In a series of Cox proportional hazards models controlling for age, sex, and education, a one-point higher dyssomnia score at baseline was associated with about 20% increased risk of IADL disability (hazard ratio: 1.20; 95% confidence interval [CI]: 1.04-1.39; χ(2)1 = 7.62; p <0.05), about 27% increased risk of ADL disability (hazard ratio: 1.27; 95% CI: 1.10-1.47; χ(2)1 = 12.15; p <0.01), and about 27% increased risk of mobility disability (hazard ratio: 1.27; 95% CI: 1.09-1.48; χ(2)1 = 11.04; p <0.01). These associations did not vary by age, sex, or education and remained significant after controlling for potential confounders including body mass index, chronic medical conditions, and several common medications. Controlling for depressive symptoms attenuated the association between sleep complaints and incident IADL and ADL disabilities but the association between sleep complaints and incident mobility disability remained significant. CONCLUSION Non-disabled older adults with more sleep complaints have an increased risk of developing disability.

Home dim light melatonin onsets with measures of compliance in delayed sleep phase disorder

The dim light melatonin onset (DLMO) assists with the diagnosis and treatment of circadian rhythm sleep disorders. Home DLMOs are attractive for cost savings and convenience, but can be confounded by home lighting and sample timing errors. We developed a home saliva collection kit with objective measures of light exposure and sample timing. We report on our first test of the kit in a clinical population. Thirty‐two participants with delayed sleep phase disorder (DSPD; 17 women, aged 18–52 years) participated in two back‐to‐back home and laboratory phase assessments. Most participants (66%) received at least one 30‐s epoch of light >50 lux during the home phase assessments, but for only 1.5% of the time. Most participants (56%) collected every saliva sample within 5 min of the scheduled time. Eighty‐three per cent of home DLMOs were not affected by light or sampling errors. The home DLMOs occurred, on average, 10.2 min before the laboratory DLMOs, and were correlated highly with the laboratory DLMOs (r = 0.93, P < 0.001). These results indicate that home saliva sampling with objective measures of light exposure and sample timing, can assist in identifying accurate home DLMOs.

Management of Obstructive Sleep Apnea and Comorbid Insomnia: A Mixed-Methods Evaluation

The purpose of this study was to examine the process of care in an interdisciplinary sleep clinic for patients with obstructive sleep apnea (OSA) and comorbid insomnia. A mixed-methods approach was used to examine clinical and patient-centered measures for 34 patients who received positive-airway pressure for OSA or cognitive-behavior therapy for insomnia. The results revealed baseline-to-follow-up improvements on several self-reported sleep parameters and measures of daytime functioning. Qualitative analyses from patient interviews revealed three themes: conceptual distinctions about each sleep disorder, importance of treating both sleep disorders, and preferences with regard to the sequence of treatment. These findings indicate that patients with OSA and comorbid insomnia encounter unique challenges. A dimensional approach to assessment and treatment is proposed for future research.

Morning Versus Evening Bright Light Treatment at Home to Improve Function and Pain Sensitivity for Women with Fibromyalgia: A Pilot Study

Objective. To test the feasibility, acceptability, and effects of a home-based morning versus evening bright light treatment on function and pain sensitivity in women with fibromyalgia. Design. A single blind randomized study with two treatment arms: 6 days of a 1 hour morning light treatment or 6 days of a 1 hour evening light treatment. Function, pain sensitivity, and circadian timing were assessed before and after treatment. Setting. Participants slept at home, except for two nights in Sleep Center. Participants. Ten women meeting the American College of Rheumatology’s diagnostic criteria for fibromyalgia, including normal blood test results. Methods. Self-reported function was assessed with the Fibromyalgia Impact Questionnaire (FIQ). Pain sensitivity was assessed using a heat stimulus that gave measures of threshold and tolerance. Circadian timing was assessed with the dim light melatonin onset. Results. Both morning and evening light treatments led to improvements in function and pain sensitivity. However, only the morning light treatment led to a clinically meaningful improvement in function (>14% reduction from baseline FIQ) and morning light significantly increased pain threshold more than evening light (P < 0.05). Phase advances in circadian timing were associated with an increase in pain tolerance (r = 0.67, P < 0.05). Conclusions. Bright light treatment appears to be a feasible and acceptable adjunctive treatment to women with fibromyalgia. Those who undergo morning light treatment may show improvements in function and pain sensitivity. Advances in circadian timing may be one mechanism by which morning light improves pain sensitivity. Findings can inform the design of a randomized controlled trial.

Insomnia in Parkinson’s Disease

Insomnia is the most common sleep disorder in Parkinson’s disease (PD). Sleep maintenance insomnia is the most common type of insomnia in this population. The pathophysiology of insomnia is complex and not fully understood. Contributing factors to insomnia in PD include complex medication regimens and comorbidities associated with the disease. A dedicated sleep interview that includes patients’ bed partners or care givers is a necessary diagnostic step in the management of insomnia. Treatment options include non-pharmacological and pharmacological approaches.

Can Circadian Dysregulation Exacerbate Migraines

This observational pilot study examined objective circadian phase and sleep timing in chronic migraine (CM) and healthy controls (HC) and the impact of circadian factors on migraine frequency and severity.

An Adaptive Treatment to Improve Positive Airway Pressure (PAP) Adherence in Patients with Obstructive Sleep Apnea: A Proof of Concept Trial.

Despite the benefits of positive airway pressure (PAP) treatment, rates of adherence to treatment are suboptimal. This proof-of-concept study assessed the feasibility, acceptability, and clinical significance of an adaptive treatment strategy to improve adherence to PAP. All participants first completed a brief educational intervention. Those who did not show at least a 25% increase in PAP use were randomized to receive a second, more intensive intervention, either motivational enhancement treatment or self-management treatment. Results suggested adequate feasibility and acceptability. In addition, participants demonstrated significant increases in objective PAP use, improvements in sleep quality, and decreases in daytime sleepiness. This study represents a first step in the development and validation of an adaptive treatment strategy to improve PAP adherence.