Almost half of all migraine attacks occur between 4 am and 9 am.[i]
Waking up with a migraine or headache is common. The time of the attack can be an important clue in finding the appropriate treatment and prevention.
You can be awoken by a migraine at any time.
There are a number of factors which may cause or trigger an attack. Like migraine triggers generally, some of these factors alone may be enough to cause you to wake up with a migraine.
In other cases, it may be a combination of factors that push you over your ‘migraine threshold’, a concept that is discussed in greater detail in our Trigger Guide section.
Triggers that affect you may not affect others so the challenge is to uncover which of the below causes may be affecting you and potentially contributing towards your attacks.
From personal experience, triggers rarely work in isolation. In my case they are almost always accompanied by several other triggers when problems begin to arise.
1. Poor Sleep Habits
Poor sleep is a common migraine trigger.
Adequate sleep is an essential part of migraine management. It’s also a restorative brain function which influences many other aspects of the body.
Sleep, headache and mood all share common neurotransmitters. Neurotransmitters are the brain’s messaging system.[i] Inadequate sleep increases the chances of headache and changes in mood.
Sleep loss also amplifies the physical and emotional experience of pain. In other words, sleep loss lowers the pain threshold. Fortunately the reverse is also true. Restful sleep improves your pain threshold and lifts your mood.[i]
Any of the following can be a sleep related migraine trigger:
- Too little sleep
- Too much sleep
- Disrupted sleep
- Poor quality sleep
- Irregular sleep routines (i.e. shift work)
- Dramatic shifts in sleep routine (i.e. jetlag)
If you have a headache disorder like migraine chances are you have a sleeping disorder too. A study of 1,283 migraine patients found that over half had reported difficulty getting to sleep and maintaining sleep at least occasionally. [ii]
The same study also found that sleep disturbance triggered migraine attacks in 50% of patients.
For those with chronic migraine or headache you’re at least twice as likely than the average individual to have a sleep disorder. Some sources suggest up to eight times more likely.[i]
Adults in general are poor sleepers in today’s fast-paced society. The US Center for Disease Control (CDC) said “insufficient sleep is a public health problem”.
The National Sleep Foundation found that 60% of adults reported having sleep problems a few nights a week or more.
Sleep may be an issue when you:
- wake up tired
- get sleepy during the day and feel the need to nap
- have difficulty falling asleep
If you are woken regularly or even daily with a headache or migraine it is referred to as “awakening headache”. These may share symptoms with migraine, tension type headache or other type of headache such as cluster headache.
As the name suggests, an awakening headache tends to occur shortly after waking in the morning.
Research has found that 71% of migraine patients reported awakening headache during the study period. [ii]
2. Sleep Disorders
Sleep apnea occurs when breathing is interrupted temporarily whilst an individual is asleep. It triggers a gasp for breath and often disrupts sleep quality without fully awaking the individual.
Many people with apnea do not realise they have it and 80% of people have not been diagnosed.[iii] It’s often the partner, wife or husband who alerts them to the problem.
Sleep apnea is often associated with migraine but researchers still debate the strength of its association. [iv]
Snoring is a potential symptom of sleep apnea. It’s often the first sign of abnormal breathing but does not always indicate obstructive sleep apnea.
Insomia is the most common sleep issue for those with headache. [i] It includes difficulty falling or staying asleep, non refreshing sleep or early morning awakenings.
Total sleep time with insomnia is often less than six hours per night for an adult.
Insomia is likely to led to anxiety or depression in those who experience it.
Migraine or headache combined with poor sleep and mood issues reduces quality of life and daily function. It can also lead to a negative feedback loop of increased attack frequency.
3. Medication Overuse Headache
Medication overuse headache (MOH) may be one of the most commonly underdiagnosed headache disorders that exist in those who experience daily headache or migraine attacks.
Studies have shown that up to 80% of patients presenting at a headache clinic overuse acute medication or already have MOH.[v]
MOH frequently causes daily headache or migraine attacks. It often develops over time and is the result of using acute medications too frequently.
For those who overuse medication, if a dose is administered throughout the day or night, medication levels within the body typically fall whilst the individual is asleep. Over time this leads to a dependence which can cause future attacks if the medication is withdrawn. MOH is frequently referred to as rebound headache for this reason.
Caffeine is a drug that can develop dependence within a week. Once dependent, if you do not get your regular “hit” of caffeine you may experience a withdrawal headache or in those susceptible, migraine.
High caffeine consumption is a risk factor for progression to chronic migraine.[vi]
If you have chronic migraine or headache, doctors often advise patients to avoid caffeine.
Some treatments for migraine may include caffeine (such as Excedrin) because caffeine can enhance the effect of the treatment. These treatments should be used cautiously to avoid contributing to MOH.
If caffeine is an important part of your life then keeping caffeine levels regular and consistent is helpful to prevent caffeine withdrawals.
Stress is another common cause of sleep problems.
According to the Anxiety and Depression Association of America, one in three of adults report persistent stress or excessive daily anxiety. 70% of the same group admit to having trouble sleeping.
Stress or anxiety can make it difficult to fall asleep with ‘racing thoughts’ and sleep difficulties which often exacerbate stress and anxiety.
Have you lied in bed worrying or getting frustrated about not getting to sleep when you really needed it?
This emotional stress can create a negative feedback loop of stress fuelling sleep issues and sleep issues fuelling further stress.
6. Jaw Clenching or Grinding
Grinding or clenching teeth can occur without the individual even realizing it. You may wake up with a headache or even a migraine but not notice symptoms from the jaw.
Clenching throughout the night can lead to fatigue and exhaustion of jaw muscles.
Individuals may notice a stiff jaw, aches in the temples and even damaged teeth. Extreme forces can occur in individuals who grind or clench during sleep. This is often several times more forceful than teeth clenching whilst awake during the day.
Let’s be honest with ourselves. Many of us could be eating better. As a broad population we generally do not eat as much healthy fresh food as we should.
Personally, I don’t think perfection is realistic, but making progress and rewarding ourselves with modest indulgences is a realistic balance.
We need to consider that food is information. Not merely fuel. It can also be our poison or our medicine.
For migraine or chronic headache patients this can be particularly challenging when otherwise ‘healthy food’ can trigger attacks.
Certain foods may be triggering attacks without you being aware. Some people with migraine may not respond well to gluten, dairy or soy amongst other things.
Again, this is highly individual. The only way to really find out is through an elimination diet and a diary. Click here for a list of potential problematic foods or ingredients >>
8. Low blood sugar
Blood sugar concentration refers to the amount of glucose (sugar) in our bloodstream. The body tightly regulates blood sugar levels to keep our metabolism in balance.
Levels often rise after meals for an hour or two and then drop. After dinner, our blood sugar levels drop and continue to fall throughout the night.
Hypoglycemia refers to a condition where the blood sugar levels drop too low. Symptoms include lethargy, impaired mental function, irritability, shaking, twitching, weakness, pale complexion and sweating.
In severe cases seizures and loss of conscious may also occur. In the most severe cases, hypoglycemia can be fatal.
Dehydration is not likely to surprise many as a migraine trigger but many people don’t appreciate how easy it is to become dehydrated due to sometimes mild or subtle symptoms.
Dehydration can occur throughout the night which can trigger migraine attacks or headaches.
Alcohol is a depressant which may help initiate sleep, but it can also prevent deeper sleep states required for restorative rest.
In addition to sleep quality, alcohol can also shorten sleep duration. [vii] These factors combined may account for why so many people experience a migraine in the hours or days following alcohol consumption.
It is possible that the compromised sleep following alcohol may be a greater trigger than the actual alcohol itself.
Intoxication has become so common that we might easily forget that alcohol is a toxin and should be avoided in any significant quantity for those with chronic migraine or headache disorders.
Dr Anne MacGregor reveals “More than 50 percent of women who suffer from migraines are more prone to them around the time of their menstrual period.”
This is due to changes in the levels of female sex hormones. Men do not experience the same fluctuations. This difference may help explain why females are three times more likely to experience migraine than men.
Another hormone that could be playing a role is melatonin. Melatonin production decreases with age. [viii] Melatonin has been shown to potentially help with migraine prevention although further high quality studies are required.[ix]
12. Cluster Headache
Cluster headache is considered to be one of the most painful headaches. They are often referred to as “suicide headaches” due to the severe pain.
Some people may awake at night due to cluster headache.
Typical symptoms include pain that centers around the eye and/or in the front part of the head. It is not typically throbbing pain like migraine but rather a stabbing pain or hot poker in the eye. What characterizes cluster headache so distinctly is the restless agitation which makes it very difficult to lie still.
According to Dr Deborah Friedman at the 2016 Migraine World Summit, “80% of cluster patients have what we call episodic cluster headache, they'll get these bouts that lasts for weeks and months, and then they'll go for periods of months, or sometimes years without having cluster headaches.”
13. Hypnic Headache
Hypnic headache syndrome is a rare headache disorder that occurs exclusively at night. The cause is still unknown. Hypnic headache:
- Is rare
- Begins from 40 - 50 years old
- Occurs often between 1 am - 3 am
- Typically lasts 30-60 minutes but can last up to 6 hours.
- In some cases can also occur when napping during the day.
This type of headache is often called the “alarm clock headache” as it occurs at the same time. In a small study of 19 patients 68% experienced this headache more than 4 nights per week. [x]
It is not considered to be a migraine although it can share similar features such as unilateral pain (one side of the head), throbbing and in rarer instances sensitivity to light and sound.
14. Allergens & Chemicals
The living and breathing environment of our home can play more of a role than most people might think.
Allergans such as dust mites living in bed sheets and mattresses can cause sinus congestion and consequent headache or even migraine attacks.
Mold in the bedroom from the roof, floor or other damp areas could also lead to a range of symptoms including headaches although there is a lack of scientific evidence supporting this theory.[xi]
Chemical exposure or scents from certain products such as air fresheners, cleaners, deodorants and perfumes may also be playing a role in headaches.
15. Rare Serious Conditions
There are rare serious conditions for which you should immediately see a doctor. Two of them are brain tumors and giant cell arteritis.
Brain tumors can cause patients to wake during the night. Increased pressure from within the skull is a common first symptom. Often the headache becomes more frequent until it is constant. Learn more about the similarities of brain tumors and migraine here >>
Giant cell arteritis is an inflammation in the lining of your head arteries. It’s also known as temporal arteritis for this reason. It can occur elsewhere in the body. The most common symptoms are severe head pain and tenderness as well as fever, fatigue, jaw pain, vision loss and double vision.
How to prevent migraine or headache attacks that wake you
Develop good sleep habits
Restful sleep delivers a refreshed feeling in the morning, improved mood, cognitive function, physical energy and perhaps most importantly for chronic migraine patients – an increased threshold for pain. [i]
To improve your sleep hygiene consider some or all of the following to start experiencing the benefits:
- Setup a sleep routine: have consistent bed and wake times.
- Avoid stimuli before bed: this includes LED lights which contain stimulating light and can negatively affect melatonin production. The TV, phone and computer all emit this light.
- Temperature control: Keep the bedroom cool. The body falls asleep easier when the body temperature cools.
- Eat a few hours before bed: give your body time to empty your stomach. Avoid eating sweets or sugary foods before bed that cause large spikes in your blood sugar levels.
- Exercise during the day.
- Keep your room dark and quiet.
According to Dr Jeannetta Rains, Clinical Director of the Center for Sleep Evaluation - “The treatment of choice for insomnia is behavioral sleep therapy.” Dr Rains also suggests speaking to your health care professional about “pharmaceutical grade L-tryptophan, 5-HTP or melatonin".
Other options from sleep specialists or psychologists include:
- Cognitive therapy
- Relaxation training
- Sleep behavior modification
Low blood sugar
A light balanced snack before bedtime can help to keep blood sugar levels more stable whilst you sleep and prevent night time hypoglycemia. Look for low GI foods or combinations and avoid sugary sweets which can spike blood sugar levels.
Drinking a large glass of water right before bed is only likely to wake you during the night and disrupt your sleep.
Instead maintain good hydration levels throughout the day to help prevent dehydration whilst you sleep.
There are many ways to better manage stress:
- Exercise is a great way to relieve stress and improve your stress threshold.
- Practice relaxation training such as mindfulness meditation.
- Avoiding unnecessary stress.
- Adapt. When you cannot change the stressor, perhaps you can change how you react to it. Manage your expectations and put it in perspective. Will this really matter 10 years from now?
- Accept the things you can’t change.
Clenching or grinding is typically diagnosed by a dentist. The dentist can provide an occlusal splint, a small mouth guard to prevent teeth damage and disable the jaw from fully contracting. This dramatically reduces muscle strain and tension resulting from clenching or grinding.
Breaking the habit itself of clenching can be challenging. Stress management techniques may also be helpful.
There are several types of treatment strategies for one of the most painful types of headache. Treatments can be directed at treating the headache itself, trying to shorten the cluster period and for long term prevention.
In treating the attack, high-flow oxygen at 10-15 litres a minute in a non rebreather mask is effective in around 80% of patients according to Dr Deborah Friedman.
Interestingly, caffeine is the recommended initial treatment for hypnic headache. A recommended treatment, for example, is having caffeinated tea or coffee around bedtime. This goes against some of the healthy sleep habits outlined above, but studies have shown this can be helpful and straightforward to self administer for this particular type of headache. [xiii]
The other most helpful medicinal treatments are lithium, indomethacin and flunarizine according to a systematic review of the research literature published in Neurology. [xiii] These treatments are taken preventatively [lookup in glossary] at bed time.
Some of these treatments have common side effects which are not suitable for certain patients. Your doctor will be able to advise you whether they are appropriate or not.
Allergens & Chemicals
Minimise dust mites in your bed by using allergy proof pillowcases, mattress covers and duvets designed to minimise exposure to mites.
Wash your sheets more often and consult an allergist about your potential exposure to chemicals or irritating scents which may be affecting your home environment.
Waking with migraine or headache is a common and challenging problem. There may be multiple factors involved and it can be challenging to uncover which triggers are at work and address each of them.
Poor sleep, diet and stress levels have become so commonplace today that they are often ignored, but this may be where we can find our most sustainable results.
Let me know in the comments what factors could be waking you up with an attack?
[i] Rains, J. Sleep. Amercian Migraine Foundation. 2016 https://americanmigrainefoundation.org/understanding-migraine/sleep/ Last accessed 14 Jul 2017.
[ii] Kelman, Leslie, and Jeanetta C. Rains. "Headache and sleep: examination of sleep patterns and complaints in a large clinical sample of migraineurs." Headache: The Journal of Head and Face Pain 45.7 (2005): 904-910.
[iii] Sleep Apnea for Clinicans. https://www.sleepapnea.org/learn/sleep-apnea-information-clinicians/ Accessed Jul 13 2017
[iv] Kristiansen, Håvard Anton, et al. "Migraine and sleep apnea in the general population." The journal of headache and pain 12.1 (2011): 55-61.
[v] Sances, G. Ghiotto, N. et.al. ‘A CARE Patheway In Medication Over-use Headache: The Experience Of The Headache Centre In Pavia.’ J Headache Pain 2005; 6: 307-9.
[vi] Scher, Ann I., Walter F. Stewart, and Richard B. Lipton. "Caffeine as a risk factor for chronic daily headache A population-based study." Neurology 63.11 (2004): 2022-2027.
[vii] Palmer, C. D., G. A. Harrison, and R. W. Hiorns. "Association between smoking and drinking and sleep duration." Annals of human biology 7.2 (1980): 103-107.
[viii] Sack, Robert L., et al. "Human melatonin production decreases with age." Journal of pineal research 3.4 (1986): 379-388.
[ix] Peres, M. F. P., et al. "Melatonin, 3 mg, is effective for migraine prevention." Neurology 63.4 (2004): 757-757.
[xi] Dodick, David William, A. C. Mosek, and J. K. Campbell. "The hypnic (“alarm clock”) headache syndrome." Cephalalgia 18.3 (1998): 152-156.
[xii] Friedman, Deborah I., and Timothy De Ver Dye. "Migraine and the environment." Headache: The Journal of Head and Face Pain 49.6 (2009): 941-952.
[xiii] Evers, Stefan, and Peter J. Goadsby. "Hypnic headache Clinical features, pathophysiology, and treatment." Neurology 60.6 (2003): 905-909.