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Headaches, Snoring & OSA

by Marianne J Davey MSc

Headaches - almost everybody has suffered from them. Headache is the most common pain syndrome seen in clinical practice. Surprisingly, brain tissue itself cannot ache, and only certain structures in the head are pain-sensitive. Inside the brain, the arteries, veins, part of the outer membrane of the brain and certain cranial and cervical nerves are sensitive to pain. Outside the brain, muscles, arteries, the skull coating, nasal & sinus cavities, eyes and ears are also all sensitive to pain. Pain often results from changes in the functioning of blood vessels and muscles. Doctors usually refer to these two basic types as blood vessel headaches and muscle contraction headaches. A headache can be throbbing, dull or sharp, depending on the type. A throbbing pain is characteristic of a blood vessel headache (or vascular headache). A dull pain that acts like a tight band around the skull usually signifies a muscle contraction headache (or tension headache). A third type which causes a sharp, stabbing pain is neuralgia.

Because of its prevalence, headache is commonly seen in patients who suffer with other illnesses, such as snoring and sleep apnoea syndrome. These people often complain of morning headaches, and effective management of the headache requires knowledge of the associated illness and an understanding of the potential medications available to combat the problem. Table 1 lists some of the causes of headache that snoring and sleep apnoea sufferers may incur. If your snoring and consequent headache are caused by any of these, then they are quite easily treatable with herbal nasal sprays, nasal dilators and the new mandibular advancement device.

Pain results from changes in blood vessels and muscles

Snoring and especially sleep apnoea patients, quite often wake with a headache, which generally disappears as the day progresses. This condition is most commonly seen in obese, middle-aged men, although not exclusively. The other associated symptoms of sleep apnoea include loud snoring, daytime sleepiness, hypertension and arrhythmias.

For many snorers, tension associated with the social aspects of their problem, for example, arguments with bed partner or family and lack of sleep, cause severe headache. It is widely known that headaches are prevalent when associated with emotional stress. The tension headache is usually described as constant pressure or a band-like sensation in the frontal, temporal or occipital areas. It is thought that constant contraction and overcontraction of the scalp muscles is an important aetiological factor. In addition, tension headache has been associated with psychogenic disturbances such as depression and anxiety, both of which are also associated with patients who suffer from snoring and sleep apnoea.

Psychogenic disturbances such as depression and anxiety

Physical features can promote both excessive muscle contraction and snoring. One of these features includes temporomandibular joint dysfunction, and treatment for this condition is usually undertaken by dental, general or oral surgery and orthodontics. The use of the new mandibular advancement device may help.

Hypertensive headaches have been described as occipital or global, throbbing, and worst in the morning. Hypertensive headaches are often caused by increased levels of nervous tension, but the debate continues about how and at what level blood pressure and headache are related.

Hypertension and sleep apnoea have been associated with headaches and it has been suggested that medications used to treat both hypertension and sleep apnoea may in fact exacerbate the headache problem. This is not easy to solve as patients with hypertension need medication to control the condition. Obesity also, is one of the most common concomitant disorders of headache sufferers. It is possible that attitudes of society towards the obese may increase the psychological stresses of obese patients and further worsen their headache condition. Also many drugs used in the treatment of headache may lead to increased appetite and resultant weight gain. For the already obese this, of course, leads to further problems. When patients find themselves in this situation they should be encouraged to reduce caloric intake as well as to increase caloric expenditure through an exercise programme in order to achieve an optimal reduction in body fat. It is worth remembering that exercise is also known for its positive effects on reducing hypertension.

Table 1. Some headache types often experienced by snorers and sleep apnoea sufferers.
Type Precipitating Cause Symptoms Diagnosis Treatment
Acute maxillary sinusitis Direct extension of an infection in nasal passage through ostium of the sinus, tooth infection, allergy, polyps. Pain over the cheek with associated tenderness Hyperemia of mucus membrane, serofibrinous exudate Steam inhalation, suction, decongestant, analgesia, wet heat, antibiotics
Acute frontal sinusitis Interference of normal drainage of nasal frontal duct, oedema of mucus membranes, allergy, polyps, hyperplasia, deviation of nasal septum Severe frontal headache directly over the sinus, may radiate to vertex or behind the eyes, constant pain Morning headache, tenderness to pressure in frontal area Steam inhalation, suction, decongestant, analgesia, wet heat, antibiotics
Oral cavity (teeth, tongue, pharynx) Caries, abscess, temporomandibular joint disease May be bilateral, unilateral, variable intensity headaches, pain in jaws & mouth Lesions in oral cavity, tapping, tenderness, cold-water test Dental, general or oral surgery, orthdontics
Chronic headache may be due to excessive caffeine consumption

Excessive intake of caffeine has for a long time been considered as a cause for chronic headache. Caffeine is present in coffee, tea, cocoa, and colas, and leads to habituation and tolerance. Many sleep apnoea sufferers drink between 8 - 20 cups per day in order to remain alert, and after a missed cup or a long sleep, withdrawal headache may occur. The headache is then relieved by ingestion of caffeine. Treatment for caffeine induced headache therefore, should be a reduction in intake of caffeine or total avoidance.

Nasal stuffiness is a common cause of snoring, and also a common cause of generalised headache. The headache is present on waking and persists for a few hours, diminishing later in the morning or early afternoon. Nasal stuffiness is thought to be often due to changes in pressure dependent upon posture.

Patients with snoring and sleep apnoea conditions incur headaches mainly due to alterations in the oxygen and carbon dioxide levels in the blood. Vascular headache is caused by retained carbon dioxide. Nocturnal and early morning headaches are very common among this group of patients, where ventilation is normally poorer during sleep, and stagnation reduces clearance of secretions. The use of CPAP (Continuous Positive Airway Pressure) will alleviate these symptoms leaving the patient headache-free in the morning. Chronic congestive heart failure may also impair gas exchange through reduced ventilation or diffusion, especially at night.

Various researchers have noted the effects of carbon dioxide inhalation on subjects with headache, particularly migraine type headaches. Carbon dioxide acts as a vasodilator. When the patients are administered oxygen, the progress of the headache may be prevented.

As we all know the disabling problems of snoring are associated mainly with poor lifestyle, where overindulgence of food, alcohol or other drugs gives rise to some of the conditions discussed above. Regular exercise and improved eating habits will not only control the snoring but will almost certainly alleviate those painful and annoying headaches.