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Sleep Disorders Remain Underdiagnosed Among Pediatric Migraineurs, Study Suggests


Although rates of sleep disorders among pediatric migraineurs appear to be high, these conditions largely go undiagnosed, according to recently published study findings.

Sleep disorders (SD) are highly prevalent in pediatric patients with migraine and are often associated with a higher headache severity and lower response to acute therapy, according to results of a questionnaire-based study.

However, findings, published in the Journal of Clinical Medicine, also show that these disorders often remain undiagnosed, although improving sleep quality may reduce migraine intensity and disability and vice versa, authors wrote.

Around a quarter of children will experience a sleep problem at some point prior to adulthood, and this rate increases if an individual has a comorbid medical, psychiatric, neurodevelopmental, or neurologic condition. “Among neurologic disturbances, migraine has a strong and complex relationship with SD, although the precise nature of this association is still enigmatic,” researchers explained.

Previous research has indicated a bidirectional relationship between SD and migraine, which may be explained by alteration of the serotoninergic system or the presence of common risk factors like mood and anxiety disorders.

To better analyze the prevalence of SD in children and adolescents with migraine, investigators recruited patients at a children’s hospital in Rome, Italy, to complete 2 structured and validated questionnaires: the Children’s Sleep Habits Questionnaire (CSHQ) and Epworth Sleepiness Scale for Children and Adolescents (ESS-CHAD).

A total of 140 parents of children and adolescents with migraine completed the questionnaires, and the majority (61.4%) were female. Mean (SD) patient age was 12.1 (3.6) years and most patients (89.3%) had migraine without aura.

Of the individuals included, just 7 had received a previous diagnosis of an SD; however, 102 (72.9%) reported a CSHQ score above the cut-off and were thus diagnosed with an SD.

Analyses revealed:

  • Patients with SD presented with statistically significant higher headache frequency (P = .031) and higher prevalence of migraine equivalents (P = .007).
  • A higher CSHQ total score was associated with higher frequency of severe attacks (P = .012) and lower acute drug efficacy (P = .003).
  • Patients with a total score above the cut-off in CSHQ were 91 of 125 (72.8%) among subjects with migraine without aura, 11 of 15 (73.3%) with migraine with aura, and 6 of 10 (60%) with chronic migraine.
  • Significant positive correlations of the sleep onset delay, sleep duration, and night-wakings subscales with migraine frequency emerged.
  • A statistically significant higher prevalence of vertigo in subjects with SD compared with those without (39.2% vs 18.4%; P = .021) was found.
  • A higher prevalence of SD in children with neuropsychiatric comorbidities was found (P = .026).
  • Decreased total sleep time, as well as longer sleep onset delay and shorter sleep duration, were associated with higher frequency of migraine episodes.

Due to the low rate of SD already diagnosed in children with migraine, researchers hypothesized that “it is possible that patients with migraine attribute all their disturbances to migraine itself, thus not searching for specific help in the case of sleep disruption.”

In addition, higher nociceptive perception due to increased central sensitization and impairment of descending pain inhibitory capacity may account for disturbed sleep seen in this population, they explained. Results suggest that SD ought to be considered part of a spectrum of disorders related to migraine or of child migraine syndrome.

Data collection based on parents’ reports, in addition to a lack of objective sleep measures, mark limitations to this study. As patients were recruited from a tertiary center, they may have had more severe cases of migraine to begin with, and selection bias may also have been present in the analysis.

“The clinical evaluation of pediatric patients with migraine should always include a careful analysis of their sleep habits in order to detect the presence of SD early,” authors concluded.

“Sleep hygiene interventions and treatment of SD could improve the frequency and the intensity of migraine attacks. Moreover, implementing migraine treatment strategies, with the aid of both pharmacological and behavioral therapies, could potentially prevent patient’s sleep disruption.”


Voci A, Bruni O, Ferilli MAN, et al. Sleep disorders in pediatric migraine: a questionnaire-based study. J Clin Med. Published online August 14, 2021. doi:10.3390/jcm10163575

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