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Migraine and headache

"You don’t like your children, Mrs." (A psychologist’s opinion about migraine, 1968)

The link between sleep and migraine is often better understood by the sick people than by their doctor.
In the absence of chronobiological considerations, migraine gives way to often useless complementary explorations and sometimes to far too simplistic psychological theories.



Who never suffers from headache» ?

That ordinary symptom often disappears spontaneously (or with a simple pain killer) and rarely gives cause to consultation.
Elsewhere, migraine induces a total (but reversible) handicap, enough to be declared unfitful for service in the army, or give cause to a "mandatory" stop from work.
The link between sleep and migraine is very often better understood by the sick people themselves than by their doctor.
The relation between migraine and "stress" ("life events") too often result in "ad hoc" psychological theories which turn their back to notions of chronobiology, which are the only ones to allow to envisage a long term recovery.

Psychosomatic or lesional ?; Tension or stress?

Apart from the very rare cases of headaches related to a "malignant" AHT (gravidic hypertension f.x.) or to an arteriovenous malformation of the brain, chronic Arterial Hypertension is never the cause of the appearance of a headache. Yet, a lot of migraine sufferers "see" their tension rise at the occasion of a painful seizure (which is a normal reaction to pain).


When the (generally very complete... [1] ) checkup reveals to be normal, the repetition of the opinions leads the sick person towards considerations of psychological kind:
A family mother consults for migraines which occur preferably on Sundays and public holidays ... and strangely shifts when the National Education decides to move the childrens rest day to the previous day:
"That shows that, unconsciously, you don’t like your children, Mrs" says the psychanalyst she went to in last instance.
It is flouting chronobiology and forget to think about the consequences (major, in our opinion) of the little sleep-over this overworked mother (often a pleonasm...) allows herself on that day.

Stress, tiredness or nap ?

As a general rule, the sick person is, (by definition, Cf "Alarm system") not aware of his/her tiredness.
He/she thinks that the attack is some sort of «normal» reaction to a context of overwork or to difficult life events.
In the absence of an organic cause, the diagnosis of "simple migraine" is carried out and that’s it. The attention only focuses on the treatments of that «mal du siècle» (But medications for migraine are matters for a very powerful sales marketing).
Prescribing "migraine medication" goes faster than thinking about the cause.
Facing the failure of these treatments, some sick people even stop seeing doctors and continue suffering in silence while others enter the (sometimes obsessive) course of diets (f.x. glutenfree) which give them the illusion to control their attacks.

In the context of the «hypo-sleep syndrome», migraine is part of a clinical continuum which goes from the simple sensation of ankylosis or stiffness of the neck’s muscles, includes tension headache, and ends with the true state of «migraine sickness» which is sometimes seen by neurologists or emergency physicians in hospitals.

That context of felt emergency is particularly liable to give way to conflicts between the sick person who "feels like dying" and the competent physician who tries to restrain the resort to useless or dangerous complementary examinations (lumbar puncture or untimely scanning in emergency).

Some litigious or obsessive sick people may even condider that they are "badly taken care of" if the doctor does not give in to their request and endlessly renew medical opinions (private joke).

Clinical case

Mr D. is a generalist who ensures the continuity of care over the 24 hours of the day.
He is not able to attend his consultations when he has a migrainous attack. When it happens, he has to lie down and wait until the medication acts. Generally, the attack starts as soon as he wakes up.
Usually, he is warned the day before by the presaging symptoms called the «aura of the attack». With him, it consists in an electric sensation in the neck and visual flies.
No matter what medication he takes, the unbearable pain which drills through his head only goes away when he finally manages to sleep. His patients and family are then asked to disturb him under no circumstances.
Yet, he distrusts the rare naps or too long sleep-overs that he sometimes has to do, because the remedy can make things worse and the awakening is marked by uncomprehensible attacks.

Discussion

The migrainous subject is always extremely willing and resists a long time to overwork but since nobody is unexhaustible, that resistance leads him/her regularly to the treshold of the attack.
Like all hypos-sleep symptoms, migraine should be understood like an alarm sign and only goes away when the subject compensates his/her sleep debt.

The attack only occurs in subjects who are resistant and «deafs» enough to tiredness and it all looks as though the brain wins the struggle against will.
The aura is to be considered, in our opinion, like a neuro-dystonic expression of the organism which is exhausted and on the limit of decompensation of its resisting abilities. All tired subjects will not trigger a migraine but all migraine sufferers are tired and use all their strength to resist.

The often familial character of migraine can be explained by the fact that sleep is programmed genetically. The chronobiological balance of the "sleep pendulums" is less stable in some subjects than in others (and that, independently from the intensity of "stress").
That individual susceptibility expresses itself through a neurodystonic reaction in the case of a qualitative (or quantitative) lack of sleep.

Let us say here, as a reminder, that migraine is part of the clinical chart seen in nightworkers who are not adapted to diurnal sleep.
Only a somnological (chronobiological) approach of migraine and, sometimes, the one-off use of a sleeping pill (preferably before the start of an attack), could, in our opinion, contribute to control its occurrence...

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Poor sleepers and unaware of it ?

Yet, in our experience, while all sick people admit that they were exhausted and that the attack only goes away when they get some sleep, very few understand the role of sleep in the occurrence of the attacks. This comes from the fact that there often exists a compensation hypersomnia when the attack is close and the subject thinks, in the opposite, that he/she sleeps a lot !

Footnotes

[1A migraine requires no complementary investigation provided the attack responds to the usual criteria for typical migraine, and the clinical and neurological examination is normal.
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