The East Bay Headache Support Group met on May 11, 1999 to hear Richard Sankary, M.D., speak on the topic of sleep disorders. The meeting was held in the Board Room at Mt. Diablo Medical Center in Concord with 59 people in attendance.

Dr. Sankary has a background in internal medicine, then pulmonary medicine (breathing disorders), then critical care medicine, and finally sleep medicine; where he specializes in the breathing disorders of sleep. The bulk of doctors who study breathing disorders of sleep are respiratory therapists. He studied at Harvard Medical School, but he told the audience that students typically only get one hour in the curriculum of training in sleep medicine out of 4 years training. .

Dr. Sankary’s office in Pinole is the only sleep clinic in Contra Costa County. One neurologist and two respiratory doctors are now sleep-certified.

Headache is a common illness, whereas sleep disorders are very, very common condition. 40 - Fifty percent of the population has some sleep disorder. Sleep apnea is a subset of snoring, and snoring is the biggest sleep breathing disorder.

There are three basic issues of sleep disorder:

1) Abnormal activity during sleep, like snoring, seizure, sleep walking or talking.

2) Inadequate sleep--this is a universal situation in the United States in 1999.

quantity

quality

Lack of quantity of sleep is more common than lack of quality of sleep.

You can build up a sleep debt during the week which you can’t recover with a couple of extra hours of sleep on the weekend.

3) insomnia. People often have the perception of inadequate sleep--many think they don’t sleep, but they actually do, as evidencec when tested in the lab.

Dr. Sankary drew a circle around the words "sleep disorder" and then an overlapping circle labeled "chronic headache." He believes that the overlap is fairly broad. He then listed things that can have an adverse effect on sleep: external input (alcohol, etc), headache, pain, depression, medications (every medicine affects sleep in one way or another).

Pain has an impact on sleep, and depression has an effect on sleep quality--and Prozac, an antidepressant, affects sleep.

External input: Alcohol causes major problems with sleep. A nightcap causes "sleep maintenance insomnia." A drink before bed may help you to fall asleep, but alcohol is rapidly metabolized and two hours later you’ll be wide awake.

Headaches in and of themselves cause sleep disorders. Do sleep disorders cause headaches, though? Dr. Sankary said sleep disorders cause muscle pain (myalgia). A severe lack of sleep can cause headaches, then meds….in one way or another distort … ea of theses items has an impct pain has impact on sleep quality. Most meds affect quality of sleep, worst thinh if you habe insomnia is to take adrink before bed.

Dr. Sankary described a case study of a 48 year-old female who came to his office with the following complaints: Fatigue, morning frontal headaches, depression (she was on Prozac), difficulty staying awake, snoring, and allergies (sinus headache).

Dr. Sankary said that many people can’t stay awake during the day--even truckers will have micro sleeps as they’re driving. A person who can fall asleep anytime, anywhere has a sleep disorder. The measurement of sleepiness is directly related to the potential to have an auto accident.

We’re experiencing a bad allergy season this year in the Bay Area. Allergies cause porblems with breathing, affect headaches and cause problems with sleep.

The pharmacology of the female case study he presented: She was taking Prozac, herbals for her sinus condition, she smoked cigarettes (the junk in cigarettes causes nasal obstruction), and drank alcohol and coffee in the mornings because she’s tired.

Physical findings were: The woman was obese (she had a Body Mass Index of 30), she had high blood pressure, rhinitis (nasal congestion), and narrow air entry (in the back of her throat).

Dr. Sankary conducted a sleep study on this patient, which determined that she had bad sleep "architecture," frequent arousal, loud snoring, frequent gasping and breath holding. She woke up hundreds of times (almost every minute) during the night she spent in his sleepclinic, but she recalled only waking two or three times. This patient was monitored in the following ways: brain waves, eye activity, heart, oxygen level, breathing movements.

Your bed partner is the one who comments that you hold your breath for up to 60 secs.

Her oxygen level dropped when she held her breath during sleep. Dr. Sankary said that as we suffocate the body sees a drop in oxygen. What does the brain see?

To further describe the case study, Dr. Sankary drew a graph depicting normal sleep architecture during an eight-hour period. There are four stages of sleep--Stage 1 and Stage 2 are considered light sleep, and Stage 3 and Stage 4 are deep sleep. The night was broken up into 8 periods and a person typically cycles back and forth in all stagesm.

In the first period, this patient experienced lots of deep sleep and a short dream period (REM, or rapid eye movement). By the time the patient reached the 8th and last period of the night, there was no deep sleep, and a long dream period. Dr. Sankary explained that hormones are being released at various points during the sleep cycle.

REM-related headache disorders usually occur at the end of sleep.

Deep sleep--adults tend to lose this as they get older.

REM sleep is also called dream sleep.

If you wake a person during deep sleep, he’ll wake up feeling fatigued. A reduction or absence of deep sleep causes fatigue in the morning.

Dr. Sankary compared his 48-year-old patient:

Her oxygen dropped, she experienced many arousals; she had mostly Stage 1 and Stage 2 sleep, and very little deep sleep. She also had many suffocation periods (snoring).

Dr. Sankary said that in California where managed care is the norm, he has only one night to study a patient in his sleep laboratory, which is unfortunate. Other parts of the country get 3 nights to study a patient.

If a person is deprived of dream sleep for years, and then they get help for their snoring, or suffocation, they will start to have long periods of dreaming again, but they don’t like it.

The RX for the woman in this case study, which Dr. Sankary didn’t go into detail about, resolved her sleep abnormality and her daytime complaints, such as fatigue, headache, daytime performance. Dr. Sankary said he frequently gets home runs in the field of sleep disorders, meaning he is able to significantly help the patient. This is not as common in other fields of medicine.

Does treatment improve function? Dr. Sankary is convinced that part of the attention deficit problems in many children is that the kids are actually have sleepb problems get rid of breatging problems and perhapsleep poblems get better…sleeping…

Thirty-six percent of sleep apnea (OSA) patients had headaches, brought on by low oxygen, low blood flow. What is the cause?

About 17% of headache clinic patients had morning headaches.

about 55% of headache clinic patients with morning headaches had treatable sleep disorders.

I’m not going to fix most people who have chronic headaches. One-half of 17% may have….a morning migraine linked to deep sleep and REM. Cluster headache has been linked to REM.

Summary: Sleep disorders are common and frequently under-recognized.

Correction of sleep disorders frequently improves associated headaches.

Headaches occurring during sleep warrant consideration of a sleep disorder.

Dr. Sankary passed out a Sleepiness Test (EPWORTH) and a Sleep Diary for the audience members to take home. He said he wasn’t thrilled with the sleepiness test, though.

Q: I suffer from early morning headaches and periods of insomnia. What might be the cause?

A: Insomnia is a very difficult, common, plaguing disorder. It tortures people. Insomnia may be present with chronic fatigue syndrome. He said it’s like the chicken or the egg question, "Is it insomnia that brings on fatigue, or does fatigue cause insomnia?"

Dr. Sankary said he almost never prescribes medication for insomnia.

Other comments by Dr. Sankary: He is granted two visits per patient under managed care, and he has 15 mins to take the patient’s history. Losing weight signifantly helped sleep apnea in his patients. A sleep disorder is causally related to impotence.

During the afternoon (between 2-4 or 4-6 pm), most of us are sleepy. We force ourselves to stay awake and then we’re wide awake and active. We’re structured in 90 minute blocks--come up to light sleep every 90 minutes..

Commenting on the quality of stuff on the Internet about sleep disorders: There is lots of good, but some bad information on the Internet.

Q: Can you give us information on restless leg sleep disorders?

A. Dr. Sankary asked, "Do leg movements bother the patient in daytime? Do leg movements cause you to wake up, thus destroying your sleep architecture?" The problem is that the treatment for leg movement involves medications--and he doesn’t like to give drugs that could destroy a patient’s good sleep architecture.  The american sleep disorder assoc has a brochure on this…

Q. Can you cure insomnia in fifteen minutes?

A. Insomnia is not a simple one-cause disorder. Some of us have a genetically designed tendency to be light sleepers--and then have problems with insomnia. Group support helps this condition.

Q. Are you less likely to get a headache if awakened during light sleep than during dream sleep?

A. If you are prone to getting headaches during dream sleep, There are drugs that knock out dream sleep, but it can cause unintended problems--if you have no dream sleep then you might not get headaches, but lack of dream sleep causes fatigue.

Q. When is it appropriate to be referred to a sleep clinic?

A. 1st--Talk to your doctor. There are two basic reasons:

1) If you’re sleepy during the day even though you get lots of sleep.

2) If you are an "industrial" snorer.

Q: Is it best to sleep on your back or your side?

A. Sleeping on your back is the worst position relative to snoring. If you have back pain, though, you need to find a pain-free position for sleeping comfortably.

He said that alcohol + loud snoring = an unhappy bed partner.

Q. I am taking medication for diabetes, but find I don’t sleep as well now.

A. Dr. Sankary said that SSRI’s (antidepressants) tend to disrupt sleep. You experience much more motor activity (leg movements), and it acts as an REM suppressant.

Q. Is it normal for an adult male to need ten hours of sleep?

A. Dr. Sankary answered that the quantity of sleep a person needs is defined for each individual at a young age and stays the same throughout his lifetime. Every person needs "restorative" sleep.

Q. Does Imitrex knock out REM sleep?

A. Dr. Sankary referred this question to Dr. Michael Stein in the audience, a neurologist and medical advisor to the East Bay Headache Support. Dr. Stein said that Imitex is sedating for some patients, but not for others. He didn’t know if it would knock out REM sleep.

Q. What about taking melatonin as a supplement?

A. Dr. Sankary considers these as medications. There are problems in getting good quality stuff and in the dosing. Most insomniacs he has seen in his practice have tried melatonin and found that it didn’t work for them.

Q. What is a good source on the Internet for more information on sleep disorders?

A. Dr. Sankary has a Web page under "www.improvedsleep.com," but it’s under construction right now. Wait a month. He also mentioned you can do a search on "sleep well" and on "dement." Dr. Dement is a Stanford guy who wrote a book on the subject.

Q. Can your mattress make a difference?

A. Dr. Sankary said to check out the basics first: Check the light exposure in your room, and the noise exposure. He suggested that we don’t spend big money on an expensive mattress.

Dr. Sankary then mentioned an interesting, non-traditional therapy that we might try. It’s called "aromatherapy." He thinks the scent of lavender is sleep-inducive. There are 500 things you could do to ….

Keep a diary.

Be systematic in intervention.

Talk to someone with a knowledge of those agents.

Q. What is the real function of sleep? What does it really do? Why is it there?

A. Sleep is required for every body (man or animal). If a body is absolutely deprived of sleep, death results. Sleep has restorative properties. We have crazy biologic clock (hormones are released at various times of the day/night. You can distort the immune functions of the body with lack of sleep. Sleep is fundamental to functioning.

A young child is irritable if he misses his nap.

Adults with sleep disorders may be irritable.

Kids have profound problems with motor functions with lack of sleep.

So much craziness now, we don’t respect value of good sleep.

Q. Reg: I can’t imagine being in a sleep lab all wired up. How do you go to sleep?

A. It doesn’t work with insomniacs--light sleepers are hard to study.

Q. Jet lag--can you make it up?

A. Yes. You can’t make it up on the weekend if you’re…