Headaches and Sleep Disorders: New article in Cephalgia. Learn how Neuromuscular Dentistry and Sleep Dentistry can help relieve these problems.

A new article in Cephalgia discusses the comorbidities of sleep and headache. It is well established that the two most commmon causes of "Morning Headache" are TMJ disorders and Sleep Apnea. There is an excellent paper fron the National Heart Lung and Blood Institute on the relation of these two disorders. The paper "CARDIOVASCULAR AND SLEEP-RELATED CONSEQUENCES OF TEMPOROMANDIBULAR DISORDERS" can be found at www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf

The article in Cephalgia stated
Adults with severe headache are at significantly higher risk of also suffering from sleep problems, when compared with the general population, regardless of specific headache type. Optimal treatment of headache must include investigation for sleep disorders and vice versa."

The two primary sleep disorders associated with headache in my experience are sleep apnea and maintenance insomnia. Maintenance insomnia is usually the result of sleep apnea/ UARS (upper airway resistance syndrome) or restless legs (periodic leg movements in sleep PLMS)

Patients pesenting with severe stree frequently have sleep onset insomnia. Chronic pain frequently leads to stress(cortisol) disorders.

Treatment of Sleep Apnea is considered the Gold Standard for Sleep Apnea but most patients do not tolerate treat and abandon it completely (up to 60%) or more commonly use it only a few hours a night which is leaves significant residual disease and risks of cardiovascular disease, excessive daytime sleepiness, tiredness, headaches and migraines.

An excellent alternative treatment for sleep apnea is an oral appliance (http://www.ihatecpap.com) It is extremely effective for Upper Airway Resistances Syndrome, Snoring Arousals, and mild to moderate sleep apnea. It has been shown to be effective in severe sleep apnea but is usually not effectively in the morbidly obese. Morbidily obese patients with headaches and migraines are probably CPAP candidates but oral appliance therapy can be used if they do not tolerate CPAP.

Treatment of Sleep Disordered Breathing can be remrkably effective in treating many types of headaches, especially morning headaches. Oral Appliances are preferred by the majority patients over CPAP when they are offered a choice. A side effect of oral appliance therapy is bite changes. Exercises taught to patients can prevent most changes but many patients chose not to do the exercises. The reason is that when the jaw is advanced for 8 hours it "heals" in this new position frequently eliminating headaches and migraines. While dentists treating sleep apnea with oral appliances usually try to prevent bite changes dentists treating patients for TMJ disorders (TMD) chronic tension headaches and migraines actually welcome bite changes.

Daytime headaches are very effectively treated with a different type of oral appliance called a neuromuscular orthotic. If the headaches are eliminated a second phase of treatment can make these changes permanent. Understanding that TMD and Sleep Apnea are different faces of the same structural/developmental disorder.

Another pertinent and timely study J Headache Pain. 2011 Aug 17. "Clinical features of headache patients with fibromyalgia comorbidity." looks at chronic heqdaches and fibromyalgia comorbidities with tension headache, chronic daily headacahe and migraine. These are comorbidities to TMJ disorders (TMD) and problems of the Trigeminal Nervous system that is over one half of the total input to the brain.

Sleep disorders as well as tension-type headaches, chronic daily headaches and fibromyalgia can all be substantially improved in most patients with various types of oral orthopedic appliances that not only alter posture and airway but can change the autonomic overload from noxious stimuli into the trigeminal system. One appliance is specifically approved for migraine prevention.




Cephalalgia. 2011 Apr;31(6):648-53. Epub 2011 Jan 10.
Headaches and sleep problems among adults in the United States: findings from the National Comorbidity Survey-Replication study.
Lateef T, Swanson S, Cui L, Nelson K, Nakamura E, Merikangas K.
Source

National Institute of Mental Health, USA. TLateef@cnmc.org
Abstract
BACKGROUND:

Several studies have demonstrated an association between headache and disturbed sleep. None have examined this association across the headache spectrum. Our goal was to determine whether migraine and migraine with aura differ from nonmigraine headache in terms of associated insomnia complaints or severity of sleep problems.
METHODS:

A probability sample of US adults was used. A structured interview administered by trained interviewers was used. Diagnostic criteria for migraine and migraine with aura were based on the International Headache Society classification. The presence or absence of four forms of sleep disturbance associated with an insomnia diagnosis was ascertained.
RESULTS:

There was a significant association between frequent severe headache, including migraine with and without aura, and disordered sleep. Adults with headache reported more frequently difficulty initiating sleep (odds ratio [confidence interval] = 2.0 [1.6-2.5]), difficulty staying asleep (2.5 [2.1-3]), early morning awakening (2.0 [1.7-2.5]) and daytime fatigue (2.6 [2.2-3.2]) and also were more than twice as likely to report three or more of these symptoms(2.5 [2-3.1]) compared to the individuals without headache.
DISCUSSION:

Adults with severe headache are at significantly higher risk of also suffering from sleep problems, when compared with the general population, regardless of specific headache type. Optimal treatment of headache must include investigation for sleep disorders and vice versa.

PubMed abstracts below:

Comment in * Cephalalgia. 2011 Apr;31(6):643-4.

J Headache Pain. 2011 Aug 17. [Epub ahead of print]
Clinical features of headache patients with fibromyalgia comorbidity.
de Tommaso M, Federici A, Serpino C, Vecchio E, Franco G, Sardaro M, Delussi M, Livrea P.
Source

Neurophysiopathology of Pain Unit, Neurological and Psychiatric Sciences Department, Medical Faculty, Policlinico General Hospital, Aldo Moro University, Neurological Building, Piazza Giulio Cesare 11, 70124, Bari, Italy, m.detommaso@neurol.uniba.it.
Abstract

Our previous study assessed the prevalence of fibromyalgia (FM) syndrome in migraine and tension-type headache. We aimed to update our previous results, considering a larger cohort of primary headache patients who came for the first time at our tertiary headache ambulatory. A consecutive sample of 1,123 patients was screened. Frequency of FM in the main groups and types of primary headaches; discriminating factor for FM comorbidity derived from headache frequency and duration, age, anxiety, depression, headache disability, allodynia, pericranial tenderness, fatigue, quality of life and sleep, and probability of FM membership in groups; and types of primary headaches were assessed. FM was present in 174 among a total of 889 included patients. It prevailed in the tension-type headache main group (35%, p < 0.0001) and chronic tension-type headache subtype (44.3%, p < 0.0001). Headache frequency, anxiety, pericranial tenderness, poor sleep quality, and physical disability were the best discriminating variables for FM comorbidity, with 81.2% sensitivity. Patients presenting with chronic migraine and chronic tension-type headache had a higher probability of sharing the FM profile (Bonferroni test, p < 0.01). A phenotypic profile where headache frequency concurs with anxiety, sleep disturbance, and pericranial tenderness should be individuated to detect the development of diffuse pain in headache patients.

PMID:
21847547
[PubMed - as supplied by publisher]

Labels: chronic daily headaches, dental sleep medicine, fibromyalgia tension type headaches, headaches migraines, insomnia migraines, migraines sleep, sleep apnea migraines

posted by Dr Shapira at 2:42 PM

Pain Medications May Cause Sleep Apnea

According to at least one study, sleep disordered breathing, including sleep apnea, was common among users of opioid pain medications for chronic pain. The study, published in the journal Pain Medicine, showed that up to three-quarters of users of opioid pain medications suffered from sleep apnea, nearly 10 times the rate in the general population.

Although many of the sufferers had obstructive sleep apnea, up to a third of them suffered from central sleep apnea. In addition, the researchers found that there was a dose-dependent effect of certain opioid pain medications on the severity of central sleep apnea. Methadone and benzodiazepines had dose-dependent relationships with the severity of central sleep apnea.

Unfortunately, pain medication and sleep apnea have a vicious cyclical relationship. Sleep apnea sufferers often see less effect from pain relievers, which may trigger them to move on to stronger opioid medication for chronic pain, which then will increase the severity of their sleep apnea. As sleep apnea worsens, people suffer an increased risk of heart attack, stroke, and other potentially deadly health consequences.

If you are taking chronic pain medication or if you have chronic pain that you are considering medication for, you should be evaluated for sleep apnea so that you can receive appropriate treatment to reduce the risks associated with this vicious cycle.

To learn more about sleep apnea and sleep apnea treatments, please contact a local sleep dentist today.

Study Confirms Long-Term Effectiveness of Behavioral Treatment for Sleep Apnea

We have long known that behavioral treatment is an effective complement to other types of obstructive sleep apnea treatment. Now a recent study has confirmed its long-term effectiveness is so great that for some patients it may completely replace other forms of treatment.

The study, published in the BMJ, builds on initial results for a short-term trial in which patients were put on a very-low calorie diet for nine weeks in order to lose weight. The patients were then given counseling and advice about nutrition and exercise for one year. Over the year, patients who had lost weight maintained the weight lost, and many saw significant improvement in their sleep apnea. 48% of patients on the diet program no longer required CPAP for their sleep apnea, and 10% saw complete remission of their sleep apnea.

Behavioral treatment is not always the best option, but it is almost always an effective complement for people looking to get the best treatment possible for their obstructive sleep apnea. If you are being prescribed CPAP treatment and you feel your doctor has not adequately considered other treatment alternatives, perhaps you need a second opinion.

To learn more about treatment alternatives, please contact a local sleep dentist today.

Hotel Launches "Anti-Snoring Room"

Crowne Plaza is the first hotel chain to offer what it describes as "snore absorption rooms." These rooms are ostensibly the result of research that has been done on the impact of snoring on UK couples' snoring habits. According to the research, snorers' cosleepers lose between one and five hours of sleep a night due to their partners' sleep disordered breathing. A similar proportion also reports that their vacations are ruined by snoring, so anti-snoring rooms make sense for the satisfaction of a hotel's clients.

Supposedly, the snore absorption rooms use "proven" technology to reduce the noise of a snorer's breathing. This technology includes:

• · Sound proofing on walls to absorb and deflect the sound of snoring
• · Sound-absorbing headboards that supplement the sound absorption of the walls
• · An anti-snoring bed wedge that encourages side-sleeping or upright sleeping, which can stop the sound created by positional snorers
• · An anti-snoring pillow which uses "rare" neodymium magnets that open the airways and stiffens the upper palate to reduce sound
• · A white sound machine that drowns out snoring

There is no doubt that this is a problem that needs a solution, but the one offered by Crowne Plaza is dubious. At best, their solution simply masks the problem, and some of the technologies they propose are effective only for a limited number of people, if at all.

Instead, people who want to ensure that snoring will never ruin another vacation should seek out an effective, comfortable, portable snoring solution. The solution that best meets these criteria is an oral appliance. An oral appliance is not only a convenient solution to snoring that travelers can easily be transported when on vacation, it can also be used to treat the serious condition that snoring may signal: obstructive sleep apnea.

If you want to learn how you can reduce or eliminate your snoring for every vacation, please contact a local sleep dentist today to be evaluated for an oral appliance.

Medicare Now Covers Oral Appliance Therapy

Beginning in January of this year, Medicare began funding the use of oral appliance therapy for the treatment of sleep apnea. This will allow seniors to get the sleep apnea treatment that is best suited for them, treatment that is comfortable, flexible, and effective. What's more, unlike many private insurance companies, Medicare does not require that you first attempt to use CPAP before seeking oral appliance therapy.

In order to get coverage for your oral appliance therapy, you must meet these criteria:

• Have an evaluation by a treating physician prior to determine that you should be screened for obstructive sleep apnea

• Your sleep test must find one of the following:
• AHI or RDI of 15 events per hour with at least 30 events total
• AHI or RDI of at least 5 with ten events total AND documentation of certain sleep apnea signs or symptoms
• AHI or RDI >30, but you cannot tolerate CPAP or are otherwise not a good CPAP candidate
• Your doctor orders the device
• The device is provided and billed by a licensed dentist

In addition, not all oral appliances are covered. To meet the coding guidelines for coverage, oral appliances must:

• Have a hinged or jointed mechanism
• Be able to advance the mandible
• Able to achieve mandible advancement beyond the front teeth
• Be adjustable by you in increments of one millimeter
• Be capable of retaining adjustment when removed

As a result, tongue positioning appliances are not covered.

We can help you understand which oral appliances meet the coding guidelines for coverage. To learn more, please schedule an appointment with a local sleep dentist today.

Snoring In Children Is Dangerous According To New Study in Sleep Medicine.

A new study (PubMed abstract below) showed that even snoring (Primary Snoring = PS) is dangerous in children and like sleep apnea can lead to "behavioral, attention, and executive function difficulties are present in children with PS as well as OSAS. These results have implications for the treatment of milder forms of SDB, particularly PS, which is commonly viewed as benign."

Snoring in children can no longer be considered benign and should be carefully evaluated as it can affect a childs ability to learn and succeed.

Sleep Med. 2011 Mar;12(3):222-9. Epub 2011 Feb 15.
Neurobehavioral function is impaired in children with all severities of sleep disordered breathing.
Bourke RS, Anderson V, Yang JS, Jackman AR, Killedar A, Nixon GM, Davey MJ, Walker AM, Trinder J, Horne RS.
Source

Critical Care and Neuroscience Research, Murdoch Children's Research Institute, Melbourne, Australia.
Abstract
OBJECTIVE:

Sleep disordered breathing (SDB) is common in children and ranges in severity from primary snoring (PS), to obstructive sleep apnea syndrome (OSAS). This study investigated everyday function (behavior, attention, executive skills) in children with varying degrees of SDB and control children with no history of SDB recruited from the community.
METHODS:

One hundred thirty-six children aged 7-12 were studied. Routine overnight polysomnography (PSG) classified children into 4 groups: PS (n=59), mild OSAS (n=24), moderate/severe OSAS (n=18), and controls (n=35). Behavioral function and behavioral aspects of attention and executive function were assessed using the Child Behavior Checklist (CBCL) and the Behavior Rating Inventory of Executive Function (BRIEF).
RESULTS:

Children with all severities of SDB had significantly higher rates of total, internalizing and externalizing behavioral problems compared to control children. Increased rates of behavioral executive dysfunction were also found across the SDB spectrum.
CONCLUSION:

Our findings suggest that behavioral, attention, and executive function difficulties are present in children with PS as well as OSAS. These results have implications for the treatment of milder forms of SDB, particularly PS, which is commonly viewed as benign.

Pillars Do Not Reduce CPAP Pressure or Increase CPAP compliance.

Patients with sleep apnea are frequently looking for an easy surgical procedure to treat their sleep apnea. Pillar surgery was intially considered to be a treatment for sleep apnea but has been relegated to a treatment for simple snoring coming from the soft palate.

PLACEMENT OF SOFT PALATE PILLARS SHOULD NOT BE CONSIDERED A PRIMARY TREATMENT FOR SLEEP APNEA!

A new study (PubMed abstract below)looked at Pillar Surgery to see if it increased compliance in CPAP users or decreased CPAP pressures. Sadly, this was not the case. The study published in Otolaryngology Head and Neck Surgery concluded that "Pillar implants do not significantly reduce CPAP pressure or increase CPAP compliance compared to sham controls but may subjectively improve CPAP satisfaction. These findings do not presently support the use of Pillar implants as an adjunctive treatment to improve CPAP compliance."

I advise patients who are looking for a surgical "cure" for sleep apnea avoid pillar surgery. Surgical interventions that can "cure sleep apnea" are available. The most successful is bimaxillary advancement. Base of tongue reduction is also successful but I strongly recommend doing it with the somnoplasty method to avoid adverse surgical consequences.

For the severely obese CPAP and tracheotomy are the most successful treatments. Mild to moderate sleep apnea is best treated with CPAP or Oral Appliances.

Otolaryngol Head Neck Surg. 2011 Feb;144(2):230-6. Epub 2010 Dec 29.
Effect of palatal implants on continuous positive airway pressure and compliance.
Gillespie MB, Wylie PE, Lee-Chiong T, Rapoport DM.
Source

Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina 29425-5500, USA. gillesmb@musc.edu
Abstract
OBJECTIVE:

Determine if the Pillar palatal implant system reduces continuous positive airway pressure (CPAP) pressure and improves patient compliance with CPAP therapy.
STUDY DESIGN:

Randomized, double-blind, placebo-controlled study.
SETTING:

Four geographically dispersed tertiary sleep disorder referral centers.
METHODS:

Subjects with mild to moderate sleep apnea dissatisfied with CPAP because of pressure-related complaints were randomized to receive Pillar implants or a sham procedure performed in double-blind fashion. Active and sham groups were compared for changes in therapeutic CPAP pressures (primary outcome) with a 90-day follow-up sleep study and CPAP compliance (secondary outcome) with a 90-day smart card report.
RESULTS:

Twenty-six subjects were randomized to Pillar implants and 25 to a sham implant procedure. There were no differences between groups with regard to demographics and baseline parameters. Both sham and active groups had reduced mean CPAP pressure (-1.1 vs -0.5 cm H(2)O) with no difference between groups (P = .32) at 90-day follow-up. In addition, there was no difference in average daily CPAP use between groups (P = .80). Both groups experienced improvements in Epworth sleepiness scores and Functional Outcome of Sleep Questionnaire scores at 90 days with no differences between groups. The active group reported significantly higher CPAP satisfaction scores than the sham group (P = .04).
CONCLUSION:

Pillar implants do not significantly reduce CPAP pressure or increase CPAP compliance compared to sham controls but may subjectively improve CPAP satisfaction. These findings do not presently support the use of Pillar implants as an adjunctive treatment to improve CPAP compliance.

PMID:
21493422
[PubMed - indexed for MEDLINE]