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  • Open Access

Answer to comment on “sleep quality, arousal and pain thresholds in migraineurs: a blinded controlled polysomnographic study”

The Journal of Headache and Pain201314:56

  • Received: 29 May 2013
  • Accepted: 25 June 2013
  • Published:


We discuss the comments on our article “Sleep quality, arousal and pain thresholds in migraineurs. A blinded controlled polysomnographic study” published in JHP 2013 Feb 14;14(1):12. We hypothesize that migraineurs need more sleep than healthy controls and more sleep than they manage to achieve. Some migraineurs probably have a decreased ability to process incoming stimuli. Increased spontaneous pain may follow either sleep restriction or sleep disturbance. A comparison of migraineurs with attack onset related to sleep, migraineurs with attack onset not related to sleep and controls will be reported in another paper.


  • Migraine
  • Sleep
  • Sleep deprivation
  • Arousal
  • Pain


We thank the group at Institute of Neurology, Catholic University in Rome for the comments [1] on our article [2]. We are delighted to get this opportunity to improve and clarify the interpretation of our findings. It is especially gratifying to answer comments from this group as the publication from 2006 “Dysfunction of arousal system in sleep-related migraine without aura” by Della Marca et al. [3] has been an important and inspiring article during our work with this project.

In our study the migraineurs reported normal sleep times and increased daytime tiredness while we found polysomnographic signs indicating foregoing sleep deprivation. We therefore hypothesized that migraineurs need more sleep than healthy controls and more sleep than they manage to achieve. The relevance of sleep deprivation in migraineurs is amplified by signs of even stronger sleep pressure in the early migraine phase as reduced latency to sleep onset was present.

Both reduced and increased sleep and change in sleep pattern are reported as migraine triggers [47]. Even small delays in bedtime can probably release an attack if the need for sleep is increased. Long sleep is not the most frequently reported migraine trigger and the importance of long sleep itself might be questioned as weekend migraine seems infrequent [8]. To speculate, long sleep periods are probably associated with increased sleep depth which itself seems to be a risk factor for migraine [2, 9]. Furthermore, a period of planned sleep restriction most likely is less stress- and harmful than repeated and irregular disturbances during sleep, at least when total sleep time are equal. Repeated disturbances tend to increase light sleep while sleep restriction will increase the more restful slow wave sleep [10]. However, sleep restriction or -deprivation also increase arousal thresholds and thereby also the seriousness of respiratory disturbances [11]. This reasoning is consistent with the notion that arousals are a part of homeostatic adaptive response. High levels of (fast) arousals are probably constitutional or related to repeated occasional disturbances (of variable etiology) during sleep. After a disturbed night the sleep depth and arousal threshold tend to increase [11]. Consequently increased sleep pressure might increase the sleep quality per se but also make one more susceptible to respiratory disturbances and latent sleep apnea. It is therefore difficult to evaluate differences in pain related to sleep disturbance versus sleep restriction. However, there are reports indicating increased spontaneous pain after sleep restriction [1214] and also after sleep disturbance [10].

Sleep deprivation also reduce the ability to process incoming stimuli manifested by increased pain sensitivity and consistent with reported increased-, skin-, light noise-, smell sensitivity and testing of pain thresholds among migraineurs [1521]. However, it is uncertain if affected migraineurs are able to recover and normalize arousal levels whether insomnia is present or not. Reasonable treatment most likely should aim at not making things worse. So bottom line we think some migraineurs have reduced ability to process incoming stimuli, but to us it seems that this reduction is related to a sleep-deprived state. However, another constitutional “sleep- deprived phenotype” with some characteristics similar to narcoleptic patients in sleep [1] is possible.

In our study we did not perform CAP- scoring, but alternatively scored D- and K-bursts similar to CAP A1 bursts [22]. We intend to report results for migraineurs with attack onset related to sleep (sleep migraine) and compare them with migraineurs with attack onset not related to sleep and controls in another submitted paper. We will there also comment on slow bursts, the reported apparent paradoxical finding of reduced arousal- and increased awakening index found in the migraineurs described in our published paper in JHP [2].



Cyclic alternating pattern.


Authors’ Affiliations

Department of Clinical Neurosciences, MTFS, Norwegian University of Science and Technology, Trondheim, PB 8905, N-7489, Norway
Department of Neurology and Clinical Neurophysiology, St. Olavs Hospital, Trondheim, N-7006, Norway
Norwegian National Headache Centre, St. Olavs Hospital, Trondheim, N-7006, Norway
Department of Neurology, Haukeland University Hospital, Bergen, N-5021, Norway
Department of Clinical Medicine, University of Bergen, Bergen, N-5021, Norway


  1. Vollono C, Testani E, Losurdo A, Mazza S, Della Marca G: Migraine, arousal and sleep deprivation: comment on: “sleep quality, arousal and pain thresholds in migraineurs: a blinded controlled polysomnographic study”. J Headache Pain 2013,14(1):50. 10.1186/1129-2377-14-50PubMed CentralPubMedView ArticleGoogle Scholar
  2. Engstrom M, Hagen K, Bjork MH, Stovner LJ, Gravdahl GB, Stjern M, Sand T: Sleep quality, arousal and pain thresholds in migraineurs: a blinded controlled polysomnographic study. J Headache Pain 2013,14(1):12. 10.1186/1129-2377-14-12PubMed CentralPubMedView ArticleGoogle Scholar
  3. Della Marca G, Vollono C, Rubino M, Di Trapani G, Mariotti P, Tonali PA: Dysfunction of arousal systems in sleep-related migraine without aura. Cephalalgia 2006,26(7):857–864. 10.1111/j.1468-2982.2006.01122.xPubMedView ArticleGoogle Scholar
  4. Andress-Rothrock D, King W, Rothrock J: An analysis of migraine triggers in a clinic-based population. Headache 2010,50(8):1366–1370. 10.1111/j.1526-4610.2010.01753.xPubMedView ArticleGoogle Scholar
  5. Hauge AW, Kirchmann M, Olesen J: Characterization of consistent triggers of migraine with aura. Cephalalgia 2011,31(4):416–438. 10.1177/0333102410382795PubMedView ArticleGoogle Scholar
  6. Kelman L: The triggers or precipitants of the acute migraine attack. Cephalalgia 2007,27(5):394–402. 10.1111/j.1468-2982.2007.01303.xPubMedView ArticleGoogle Scholar
  7. Martin PR: Behavioral management of migraine headache triggers: learning to cope with triggers. Curr Pain Headache Rep 2010,14(3):221–227. 10.1007/s11916-010-0112-zPubMedView ArticleGoogle Scholar
  8. Alstadhaug KB, Salvesen R, Bekkelund S: Weekend migraine. Cephalalgia 2007,27(4):343–346. 10.1111/j.1468-2982.2007.01284.xPubMedView ArticleGoogle Scholar
  9. Houle TT, Butschek RA, Turner DP, Smitherman TA, Rains JC, Penzien DB: Stress and sleep duration predict headache severity in chronic headache sufferers. Pain 2012,153(12):2432–2440. 10.1016/j.pain.2012.08.014PubMed CentralPubMedView ArticleGoogle Scholar
  10. Smith MT, Edwards RR, McCann UD, Haythornthwaite JA: The effects of sleep deprivation on pain inhibition and spontaneous pain in women. Sleep 2007,30(4):494–505.PubMedGoogle Scholar
  11. Bonnet MH, Doghramji K, Roehrs T, Stepanski EJ, Sheldon SH, Walters AS, Wise M, Chesson AL Jr: The scoring of arousal in sleep: reliability, validity, and alternatives. J Clin Sleep Med 2007,3(2):133–145.PubMedGoogle Scholar
  12. Haack M, Mullington JM: Sustained sleep restriction reduces emotional and physical well-being. Pain 2005,119(1–3):56–64.PubMedView ArticleGoogle Scholar
  13. Haack M, Lee E, Cohen DA, Mullington JM: Activation of the prostaglandin system in response to sleep loss in healthy humans: potential mediator of increased spontaneous pain. Pain 2009,145(1–2):136–141.PubMed CentralPubMedView ArticleGoogle Scholar
  14. Kundermann B, Spernal J, Huber MT, Krieg JC, Lautenbacher S: Sleep deprivation affects thermal pain thresholds but not somatosensory thresholds in healthy volunteers. Psychosom Med 2004,66(6):932–937. 10.1097/01.psy.0000145912.24553.c0PubMedView ArticleGoogle Scholar
  15. Schwedt TJ, Krauss MJ, Frey K, Gereau RW: Episodic and chronic migraineurs are hypersensitive to thermal stimuli between migraine attacks. Cephalalgia 2011,31(1):6–12. 10.1177/0333102410365108PubMed CentralPubMedView ArticleGoogle Scholar
  16. Sand T, Zhitniy N, Nilsen KB, Helde G, Hagen K, Stovner LJ: Thermal pain thresholds are decreased in the migraine preattack phase. Eur J Neurol 2008,15(11):1199–1205. 10.1111/j.1468-1331.2008.02276.xPubMedView ArticleGoogle Scholar
  17. Burstein R, Cutrer MF, Yarnitsky D: The development of cutaneous allodynia during a migraine attack clinical evidence for the sequential recruitment of spinal and supraspinal nociceptive neurons in migraine. Brain 2000,123(Pt 8):1703–1709.PubMedView ArticleGoogle Scholar
  18. Zappaterra M, Guerzoni S, Cainazzo MM, Ferrari A, Pini LA: Basal cutaneous pain threshold in headache patients. J Headache Pain 2011,12(3):303–310. 10.1007/s10194-011-0313-9PubMed CentralPubMedView ArticleGoogle Scholar
  19. Bigal ME, Ashina S, Burstein R, Reed ML, Buse D, Serrano D, Lipton RB, Group A: Prevalence and characteristics of allodynia in headache sufferers: a population study. Neurology 2008,70(17):1525–1533. 10.1212/01.wnl.0000310645.31020.b1PubMed CentralPubMedView ArticleGoogle Scholar
  20. Lovati C, D’Amico D, Bertora P, Raimondi E, Rosa S, Zardoni M, Bussone G, Mariani C: Correlation between presence of allodynia and sleep quality in migraineurs. Neurol Sci 2010,31(Suppl 1):S155-S158.PubMedView ArticleGoogle Scholar
  21. Olesen J: The international classification of headache disorders: 2nd edition, vol 24 suppl 1. Cephalalgia 2004, 24: 9–160. 2004/02/26 ednView ArticleGoogle Scholar
  22. Terzano MG, Parrino L, Smerieri A, Chervin R, Chokroverty S, Guilleminault C, Hirshkowitz M, Mahowald M, Moldofsky H, Rosa A, Thomas R, Walters A: Atlas, rules, and recording techniques for the scoring of cyclic alternating pattern (CAP) in human sleep. Sleep Med 2002,3(2):187–199. 10.1016/S1389-9457(02)00003-5PubMedView ArticleGoogle Scholar


© Engstrøm et al.; licensee Springer. 2013

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


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