Do you frequently wake up with a headache? This is a common feature with several types of headache disorders, but they are all distinct headache types with completely different treatments. Let’s discuss the 6 most common types of wake up headaches and the reasons why you may be waking up with headaches.
Migraine commonly causes wake up headaches for many patients, and is by far THE most common cause of wake up headaches. Sleep stage transitions can be a trigger for migraine attacks in many patients. Migraine is also susceptible to changes in sleep patterns. So for many, sleeping in (such as on the weekends or on vacation) can be a common (and cruel) migraine trigger leading to waking up with headaches. Thus, trying to maintain a similar sleep schedule on the weekends and weekdays can help with this type of trigger.
Other causes of wakeup headache commonly occur in patients that are stuck in chronic migraine (15-30 days per month with at least 8 headache days with migraine features), particularly if they are in rebound headache (medication overuse headache) from excess pain or “as-needed” medications. This occurs when a person with migraine is using triptans, OTCs (over-the-counter pain meds), or NSAIDs (non-steroidal anti-inflammatory drugs) more than 10 days per month, opiates or opioids more than 8 days per month, or butalbital medications such as fioricet or fiorinal more than 5 days per month, on average. Rebound headache occurs because as the patient is sleeping, the overused medication is being metabolized and eliminated from the body and the headache (typically migraine) is triggered as a result of withdrawal from the medication and the need to take more. Patients in this cycle will often notice that after they take their overused medication, the headache calms back down again. It starts to worsen again as they are due for another dose and it is wearing off. This pattern is characteristic for rebound headache. Caffeine withdrawal headache can also be a cause of wake up headaches, for similar reasons as described for rebound headache.
Treatments for migraine are discussed here. The key for abortive (as-needed) migraine treatment for waking migraines is that is must be something fast acting to have a chance to catch the migraine. The difficulty with waking migraines is that you are already “behind the ball” by the time you wake with the migraine because you’ve missed the early treatment window where most medications such as the triptans would normally be most effective. So for waking migraines, injectable Sumatriptan (Imitrex), nasal Zolmitriptan (Zomig) or Sumatriptan (Imitrex), are typically going to be the most effective triptans. With that said, sometimes patients can get away with a fast-acting oral triptan such as Rizatriptan (Maxalt) as well. Other options for waking migraines would be DHE (nasal spray or injection), or one of the gepants (Nurtec ODT, Ubrelvy, Zavspret) since they can still be effective if taken up to 4 hours past the migraine onset, which is really great and expands the migraine onset treatment window. A neuromodulatory device could also be considered.
If you are averaging more than 4 migraines per month, a daily preventive treatment is generally recommended. There are many options for this including a daily pill, natural supplements, a once monthly or quarterly CGRP monoclonal antibody (Aimovig, Ajovy, Emgality, Vyepti), Botox, gepant (Qulipta or Nurtec), or a neuromodulatory device.
2) CLUSTER HEADACHE
Cluster headache is another classic cause of wake up headaches. It is a very distinct form of headache that is easy to pick out with its characteristics. Cluster headache is classified as a trigeminal autonomic cephalalgia (TAC). There are 4 types of TAC syndromes, and cluster headache is the most common of them. The other 3 TAC syndromes are hemicrania continua, paroxysmal hemicrania, and SUNCT/SUNA, none of which are waking headache types. There are some overlapping characteristics between all 4 of these TAC headache types, but cluster headache is the only one that often wakes the patient from sleep.
Cluster headaches can occur anytime during the day, but classically occur at the same time every night, often waking the patient up from sleep, many times shortly after falling asleep within an hour or two. Men tend to be affected 3 times more than women, but it is seen in both men and women. It is a severely painful headache, and has been termed “suicide headache” at times because of the pain severity.
Cluster headache is characterized by attacks of severe unilateral (one-sided) orbital (around the eye), supraorbital (above the eye), and/or temporal pain lasting 15 to 180 minutes if untreated. There is either agitation/restlessness with the headache attack and/or at least 1 autonomic sign or symptom on the side of the headache [lacrimation (runniness/tearing of the eye), conjunctival injection (redness of the eye), facial sweating or flushing (skin turning blushed), nasal congestion, rhinorrhea (runniness of nose), sense of ear fullness, eyelid edema (swelling), or partial Horner’s syndrome (miosis (pupil becomes small)) and/or ptosis (droopiness of the eye)]. Headache attacks typically occur from 1 every other day to 8 per day for more than half the time during a cluster cycle. Chronic cluster headache is defined by attacks that occur for more than 1 year without remission, or with remission periods lasting less than 1 month.
Cluster headache attacks occur in “clusters”, or cycles, of frequent headache attacks. These cycles of cluster attacks may last for weeks or months before they go away completely. Remission periods can last months to years. Cluster cycles often occur at a predictable time of year, such as season changes (Fall and Spring are most common).
Treatments for cluster headache are discussed here. In general, at the onset of a cluster cycle, a course of high dosed Prednisone is often started over 1-2 weeks to try to break up or shorten the cycle. An abortive option is also mandatory, and the most effective options are oxygen by a face mask, injectable Sumatriptan (Imitrex), nasal Zolmitriptan (Zomig) or Sumatriptan (Imitrex), or DHE (Migranal nasal spray or injection). A preventive daily treatment is also typically started at the onset of a cluster cycle and there are a variety of options for this.
3) HYPNIC HEADACHE
Hypnic headache has also been called “alarm clock” headache because it often wakes the person up at almost exactly the same time every night. These recurrent attacks occur only during sleep, causing wakening. They typically occur on 10 or more days per month for more than 3 months. The headache lasts 15 minutes and up to 4 hours after waking. This headache usually begins after age 50, but can occur in younger ages too.
The pain is typically mild to moderate, but can be severe occasionally. The pain usually occurs on both sides of the head (as opposed to cluster headache which is 1 sided). There is no restlessness during the headache (as opposed to cluster headache). Hypnic headache is NOT associated with autonomic symptoms [lacrimation (runniness/tearing of the eye), conjunctival injection (redness of the eye), facial sweating or flushing (skin turning blushed), nasal congestion, rhinorrhea (runniness of nose), sense of ear fullness, eyelid edema (swelling), or partial Horner’s syndrome (miosis (pupil becomes small)) and/or ptosis (droopiness of the eye)] (as opposed to cluster headache which requires these autonomic symptoms for diagnostic criteria).
Treatments for cluster headache are discussed here. The most common treatments are some caffeine before bed (in those who can tolerate it and not cause insomnia), or upon waking. Indomethacin taken before bed is also a common treatment.
4) OCCIPITAL NEURALGIA
Occipital neuralgia is a miserable nagging soreness, pain, and headache in the back of the head. I tell patients to think of occipital neuralgia as “sciatica of the head”. It is sometimes associated with cervicogenic headache (headache originating from the cervical spine with associated prominent neck pain), but more commonly occurs by itself.
Occipital neuralgia is often felt in the suboccipital region (where the base of the skull meets the top of the neck) and radiates variably into the back and top of the head and behind the ears. It can less commonly even radiate to the frontal areas (by the trigeminocervical circuitry in the upper cervical spinal cord and brainstem). It can be one sided or both sides.
The pain is often described as an intense stabbing, sharp, shooting, shocking, or burning pain. It often occurs in attacks of pain which may last seconds to minutes, but can also be a continuous unrelenting pain. Sometimes it may not be as intense and may be a lower-level pain such as pressure, aching, soreness or throbbiness. Some patients may have a sensation of numbness or tingling in the back of the head. Associated neck pain is typically in the mix too. The back of the head in the area where the skull meets the neck often feels very sore or tender along the ridge of the skull bone. The pain and tenderness often increase by pushing on the back of the head and along the skull base, or lying on the back of the head. Thus, for some patients, when they lie on the back of the head during sleep, it puts pressure on the occipital nerves and they continue to get more irritated and painful until they may wake the person up from sleep due to the pain.
Treatment for occipital neuralgia is discussed in much greater deal here and here. In general, first line options are neck physical therapy to this area, as well as an anti-neuritic pain medication such a tricyclic antidepressant (TCA) of Amitriptyline (Elavil) or Nortriptyline (Pamelor), an anticonvulsant such as Gabapentin (Neurontin), or an SSRI such as Duloxetine (Cymbalta) or Venlafaxine XR (Effexor XR).
5) SLEEP APNEA HEADACHE
Sleep apnea is a common cause of a headache present upon waking in the morning. However, in comparison to the headache types listed above, this headache does not “wake you up”, but rather, you “wake up with it”. It generally fades away as the morning goes on and most often has tension type headache characteristics. So if you snore, often feel unrefreshed when you wake up in the morning, and this is associated with a headache, wake with a sore throat or dry mouth, a conversation with your doctor about possible obstructive sleep apnea evaluation should be pursued. If your bed partner witnesses times where you seem to stop breathing during sleep, then this is very likely. Sleep apnea is associated with elevated high blood pressure and increased risk of stroke and heart attack, so it is important to not let it go untreated. During the deep stages of sleep, your brain is replenishing its neurotransmitters. If you are not getting into those deep stages because the sleep apnea is disrupting progression through normal sleep stages, fatigue, memory and cognitive complaints are common.
Treatment varies depending on the severity of the sleep apnea. This is determined by an overnight sleep study called a polysomnogram. These have historically been done in a controlled setting such as a hotel room, but they are now commonly done remotely in your own bed from home too.
6) HEADACHE ATTRIBUTED TO INTRACRANIAL NEOPLASM (BRAIN TUMOR)
Lastly, brain tumor is always in the differential (and at the very top of everyone’s mind when they come in the office), depending on age, prior headache history, and other clinical symptoms. These headaches are typically associated with some other neurological complaints or findings on neurological exam such as vision deficit, imbalance, speech dysfunction, memory or cognitive impairment, or one-sided numbness or weakness. However, this isn’t an absolute, and headaches can certainly present by just themselves as well.
With all of that said, this is an uncommon reason for wake up headache or headache in general, luckily. Thus, why I have listed it last. However, it is still a reason that you should always be evaluated by your doctor for not only wake up headaches, but for any headache, especially if you don’t have a prior history of headaches, it is a different type of headache from your prior headaches, or you have any associated neurological symptoms.
These are certainly not the only causes of nocturnal headaches, but they are typically the top 6 that are evaluated for first. Disorders such as nocturnal bruxism (teeth grinding and jaw clenching) and TMJ dysfunction, or headache attributed to temporomandibular disorder can also be a contributor to headaches. However, these types of disorders don’t typically cause the patient to wake up with the pain. In addition, the pain is primarily in the temples, in the areas in front of the ear, into the face, and in the master muscles in the jaw. The headaches related to this are more often a tension type headache in description and not severe, and an ache and soreness in the jaw muscles and around the TMJ regions. A dentist should be able to easily diagnose if there is significant nocturnal bruxism happening by evaluating the teeth. Bed partners are also good historians on observations of teeth grinding during sleep.
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