NOVEMBER 13, 2001 MEETING
TOPIC:  “SLEEP AFTER 9-11”

The November 2001 meeting of the East Bay Headache Support Group featured Richard Sankary, M.D., from the Sleep Disorder Center at Doctors Medical Center in Pinole, CA, with 18 people in attendance.  Since the horrifying events of September 11 were still fresh in our minds, Dr. Sankary decided his presentation should provide the support group attendees with practical sleep-help ideas.  He passed out a handout which included 15 questions, and then suggested that if we learn anything from his presentation that changes us, that we write him a note and mail it to his office (handout and address are on Page 6).

Dr. Sankary said his initial argument is that better sleep will improve your perception and reality of headaches.  He wants to make the argument that your headache symptoms will improve.

A study was done on teenagers with headaches, and it was found that one-half of the teens experienced an improvement in their headaches when their sleep habits improved.  In a study of cluster headache sufferers, it was determined that 80% also had significant treatable sleep disorders, and when treated, the majority of their headaches improved.

Dr. Sankary is certified in four different medical subjects:  internal medicine, pulmonology (lungs), critical care medicine, and sleep medicine.

He made the statement, “A couple of ideas you learn tonight may improve your sleep and ultimately your headaches.”  And then he began to present a number of slides with rules for good sleep.

As a result of the terrorist attack on the World Trade Center and the Pentagon on September 11, our country is in acute stress disorder.  On the West Coast periodically our local refineries have accidents and people exhibit acute stress disorder also. 

Any of the following can result from acute stress disorder:

·  Numbness

·  Intrusive thoughts

·  Pervasive anxiety

·  Nightmares

·  Insomnia

·  Symptoms can last for weeks

Dr. Sankary said here in America we have such wonderful new coverage—it makes us seem like a part of the news.  He called this acute stress disorder a “National Stress Disorder.”  Americans are stressful, Americans are at war, Americans have a fear of flying, etc.

Dr. Sankary showed a picture of a rescue dog and fireman sleeping after working long hours at the World Trade Center.  The fireman was probably so physically exhausted that despite the traumatizing work, he was able to fall asleep.  But this stress can keep us from getting adequate sleep. 

After experiencing September 11, Dr. Sankary recommends:

·  Expect to be mesmerized by the news, but don’t over-saturate yourself.

·  Reduce other stressful activities.

·  Get “enough” sleep, both in quantity and quality!

·  Insufficient (of inadequate duration) or fragmented (poor quality) sleep has consequences, such as EDS, or Excessive Daytime Somnolence.  For some, this is a reality of life.  They may experience sleepiness, moodiness, neurocognitive deficits, decreased performance, higher morbidity, higher health costs, and public health issues.  More frequent headaches can also result from insufficient or fragmented sleep.  EDS is real sleepiness, where you can just fall asleep even though you’re doing something.  And it can affect your job.  Imagine someone who is an air traffic controller falling asleep at work, or a truck driver.  Dr. Sankary said that many high school and college students stay up until 2:00 a.m., and then fall asleep during class.

Dr. Sankary then presented 18 rules for good sleep, as follows:

Rule #1:

Get “enough” sleep, both in quantity and quality!  But how much is enough?  Dr. Sankary said that an optimal amount of sleep for an adult is 10 hours per night, and our bodies need 8 hours.  But few of us get that much sleep, so most are running a 90-minute daily deficit.  Dr. Sankary said that one hour of extra sleep equals a 25% improvement in daytime alertness.

Rule #2:

Maintain a regular sleep schedule, 7/24/365.  A regular sleep schedule will set and stabilize your internal clock (circadian rhythm), improve sleep quality and quantity, improve daytime alertness, and prevent “Sunday evening insomnia.”  Dr. Sankary explained that “Sunday evening insomnia” can occur if you sleep in Sunday morning and then try to go to bed at your regular time.

Rule #3: 

Strive for continuous sleep.  Fragmented sleep doesn’t work!  Six hours of continuous sleep is better than 8 hours of fragmented sleep.  Pain can have an adverse affect on sleep, and also there are sleep disorders that keep one from continuous sleep, such as sleep apnea. 

Dr. Sankary’s next slide was a “Sleep Histogram” which showed the various levels or types of sleep that we experience during a typical night.  They are light sleep, deep sleep, and dream sleep.  In the early part of the night we typically have deep sleep, but in the last part of the night there is lots of dream sleep, and no deep sleep.  If a person comes to an almost-awake state every minute, he would totally lose dream sleep and deep sleep.

Rule #4: 

Pay back lost sleep.  It often takes several days to recover from a sleepless night.  The best approach is to go to bed earlier, not have a later wake time.  The question was asked, “Should we take naps?,” and Dr. Sankary told the audience that if an adult needs to sleep during the day, something is wrong.

Rule #5: 

Reduce stress

Religion (religion of some kind is very helpful)

Relaxation

Recreation—Do more fun things

Rule #6: 

Exercise your body.  The endorphin release will keep you more alert and allows for better sleep.  Exercise enough to produce a sweat—7 times per week.  The best time to exercise is in the early morning upon awaking, or late in the afternoon.  Don’t exercise just prior to trying to sleep.  Dr. Sankary is a huge believer that regular aerobic exercise is key to good sleep, and he encouraged the audience members to include exercise in their daily plan—to make it a habit.  A person asked, “Is brisk walking enough exercise?”  Dr. Sankary answered that we don’t know.  He said it is important to use forms of exercise that will improve metabolism and release endorphins.  He recommends “sweat exercise.”  And adequate exposure to light in the wintertime helps also.

Rule #7: 

Diet.  Get to your optimum weight and stay there.  Limit the size of your evening meal.  Eat before 7:00 p.m—Dr. Sankary said that in the American culture, the largest meal of the day is dinner, and it’s late, which is bad for your sleep.  Eat a carbohydrate snack to increase tryptophan to serotonin conversion (60 minutes).  Try herbal supplements to help you sleep, such as valerian, chamomile, or primrose.  Dr. Sankary recommended a tea by Celestial Seasonings, called “Sleepytime Extra.”

Sleep Rule #8: 

No nicotine.  Nicotine messes with your brain waves (alters an EEG).  Nicotine increases the time it takes to fall asleep, increases awakenings during the night, decreases dream (REM) sleep, and decreases deep sleep.

Sleep Rule #9: 

No caffeine.  Caffeine in your bloodstream increases the time it takes to fall asleep, increases number of light awakenings during the night, and reduces dream activity during sleep.

Sleep Rule #10: 

Chocolate is the same as caffeine, as caffeine is in chocolate; and so chocolate isn’t a good choice for bedtime.  Keep chocolate to a minimum.

Sleep Rule #11:

No alcohol.  Alcohol is really bad for sleep.  Yes, it shortens the time to fall asleep, but it decreases deep sleep and dream sleep, and then increases early morning awakenings.  Drinking alcohol also tends to worsen sleep apnea.  Note that Tylenol PM has alcohol in it.

Sleep Rule #12: 

Companionship—if your relationships are good it is good for your sleep quality (release of endorphins).  And, if you have a bad relationship with someone, then your sleep will be adversely affected.  An audience member asked Dr. Sankary:  “What about 2 partners who have different internal sleep schedules?”  Dr. Sankary answered that if this is a significant disrupter, he would argue to have the couple sleep in separate beds, or even separate bedrooms.

Sleep Rule #13: 

Keep noise (BART, freeway traffic), movement, light to a minimum when trying to sleep.  And this includes disruptive partners (bed partners who snore, move around in their sleep, etc.). 

Sleep Rule #14: 

Make your bedroom a nice safe “cave.”  The cues your bedroom gives off should be that of pleasure and peace, not pain and stress.  Dr. Sankary told the story of a woman who basically lives her life in her bedroom:  She associates the bedroom with doing her tax returns, watching ballgames, etc.

Sleep Rule #15: 

Relax.  Practice yoga, progressive muscle relaxation, and/or deep breathing.  Look at a technique you can apply to reduce your stress level before bedtime, and then stick to up.

Sleep Rule #16: 

Don’t try too hard!  You can suffer from performance anxiety when trying to fall asleep.  This is a huge saboteur of sleep.  If you don’t go to sleep right away, get up and leave the bedroom.  You haven’t committed a crime to get up, but definitely avoid bright lights if you get up. 

Sleep Rule #17: 

Enjoy sleep.  Respect your body’s need for sleep.  Respect sleep as an enjoyable part of life—falling asleep shouldn’t be a medical procedure.

Sleep Rule #18: 

If you have trouble getting enough restful sleep, talk to your primary care physician about getting a referral to a sleep specialist.  Dr. Sankary commented that when he was in medical school, before he went into sleep medicine, he received only one hour of sleep training.  So, talk to a specialist.  And, if your sleep problems are serious, consider going to a sleep clinic for a work-up.

To conclude his presentation, Dr. Sankary reviewed the 18 sleep rules for the support group members.  He commented that huge benefits in coping with illnesses can be gained from improving one’s sleep.  And he’s convinced that improving sleep will resolve headache issues for some.

Dr. Sankary then asked for questions from the audience.

Q.    He was asked, “You may have a set schedule for bedtime, but can you go to bed earlier one night because you’re tired?”

 A.    Dr. Sankary said that if one has a propensity toward a sleep disorder, that he/she should work toward a standard wake up time.  As he mentioned back in Rule #4 about paying back lost sleep, the best approach is to keep your wake up time the    same—to catch up on lost sleep, you can go to bed earlier, but wake up at the same time every day.

Comment:  Dr. Stein commented that in his neurology practice, he routinely asks new headache patients whether or not they wake up with headaches.  He added that waking up with headaches is very common among his patients.

Comment:  Dr. Sankary said that when he interviews patients in his sleep medicine practice, he is looking for daytime sleepiness.  He said the husband usually will tell him that he has no problems, and he doesn’t understand why his wife insisted he see the doctor.

Q.    What do you do to treat sleep disorders?

A.    Dr. Sankary answered that the last thing he does is reach for a medicine to treat the disorder.  But, he added, if it’s pain that is keeping the patient awake, then he pushes the patient to take pain medications.   He related the story of a patient from another state who, when tested in a sleep lab, was found to kick 60 to 70 times per hour.  The man was diagnosed with restless leg syndrome, and his doctor gave him medication to stop the kicking.  But this was a big mistake for this patient, as it was discovered that he had sleep apnea, and whenever he stopped breathing, he kicked as a reaction to save himself from suffocating.

Q.    What about a sleep lab?  What does it look like?

A.    Dr. Sankary said his sleep lab looks like a hotel room—not a hospital.  It is not clinical looking, but probes are attached to record the patient’s brainwaves during the testing.  He said he always expects a “first night effect,” where the patient has problems getting to sleep because of the newness and strangeness of it.  In other parts of the U.S., sleep clinics typically see the patient 3 nights in a row.  Data from the first night is thrown out, the second night’s data is used, and the third night is for treatment.  But because of California’s managed health care, Dr. Sankary complained his sleep clinic only has 1 night to do it all.

Comment:  Dr. Sankary said when he has a patient tell him that he can fall asleep anywhere, that’s a clue that this person has a huge problem with sleep.

Q.    Is there any difference in sleep requirements as we age?

A.    Dr. Sankary answered that our sleep requirement is the same at 80 as it was at 20.  It may seem like an older person sleeps more because he naps during the day, but consider that he may be getting less sleep, or fragmented sleep, at night.  He       added that there is a sleep reality and sleep need between the 20-year-old and the 80-year-old.  We smoke, drink, or lead stressful lives, etc.  Alzheimer’s Disease and other conditions can destroy dream sleep and deep sleep.

Q.    Can a spouse identify sleep apnea (periodic not breathing)?  Can you not snore and have sleep apnea.

A.    Dr. Sankary answered “sometimes” to the first question, and “yes” to the second.

Q.    An audience member asked Dr. Sankary about obstructive sleep apnea.

A.    He answered this is equivalent to suffocating.  People are afraid they will die in their sleep.  The adrenal gland releases epinephrine (attack mode), and this can bring on high blood pressure.  He also discussed acid reflux, which can cause major choking and causes spasm of the larynx.  This is different than sleep apnea.

Q.    Is it really wrong to stay in bed when you can’t fall asleep easily?  

A.    The key is preventing you from associating your bed as a bad place to be.  How do you deal with it?  Dr. Sankary said if you do something lowkey, he has no objection to staying in bed as you wait for sleep to come.

Q.    What about herbs to help one sleep better?

A.    Dr. Sankary said he believes herbs should be treated with great respect.  He wants to see more studies done on them, both on their efficacy and safety.

The intention of the East Bay Headache Support Group is to provide information and resources.  It does not provide medical advice, which should be obtained directly from a physician.  Meeting notes do not necessarily reflect an accurate representation of the speaker’s presentation—notes were hand-written by a layperson.

SLEEP QUESTIONNAIRE

 Circle the following statements that accurately describe your habits related to sleep:

 1.    I go to bed at different times during the week and on weekends, depending on my schedule and social life.

 2.    I get up at different times during the week and on weekends, depending on my schedule and social life.

 3.    My bedroom is warm or often noisy.

 4.    I never rotate or flip my mattress.

 5.    I drink alcohol within two hours of bedtime.

 6.    I have caffeinated coffee, tea, colas, or chocolate after 6 p.m.

 7.    I do not exercise on a regular basis.

 8.    I smoke.

 9.    I regularly take over-the-counter or prescription medication to help me sleep.

10.   When I cannot fall asleep or remain asleep I stay in bed and try harder.

11.   I often read frightening or troubling books or newspaper articles right before bedtime.

12.   I do work or watch the news in bed just before turning out the lights.

13.   My bed partner keeps me awake by his/her snoring.

14.   My bed partner tosses and turns or kicks/hits me during his/her sleep.

15.   I argue with my bed partner in bed.

Source:  James Maas, Power Sleep (New York:  Villard, 1998)   

Sleep Disorders Center at Doctors Medical Center  - Richard M. Sankary, M.D., Diplomate Sleep Medicine

Pinole Campus, 2151 Appian Way, Pinole, CA 94564-2578, Tel:  510-741-2525, Fax:  510-724-2189