The Impact of Sleep and Insomnia on Migraine

0:00 [Music]
0:05 okay again thank you everybody for for
0:08 joining us for tonight’s uh Migra Canada
0:12 webinar um we have Dr Kaplan joining
0:17 us and before we We Begin we always want
0:21 to let you know that we’re proudly
0:23 supported by the sponsors that we’ve
0:25 shared on the
0:28 screen
0:33 and today’s agenda is first I’m going to
0:35 do a bit of a migraine Canada
0:37 introduction I’m then going to introduce
0:39 our speaker Dr Alan Kaplan um Dr Kaplan
0:44 will have his presentation on sleep
0:46 insomnia and migraine and at the end
0:48 we’ll do our question and
0:51 answer uh migraine Canada who we are we
0:54 are a federally registered charity
0:56 supporting all Canadians living with
0:58 migraine and other headach disorders our
1:01 mission is to improve the lives of
1:03 Canadians with migraine and other
1:04 headache disorders through advocacy
1:06 awareness education research and support
1:10 um please watch out um for the remaining
1:13 of our 2023 webinar series including our
1:16 November webinars on vestibular migraine
1:18 and then
1:19 psilocybin uh you can join our growing
1:21 community at migraine canada. org jooin
1:25 our advocacy page has great self-
1:27 advocacy tools including um form letter
1:30 templates you can find that at Migra
1:32 canada. org advocacy and check out our
1:36 library as well for our
1:40 resources before we begin we always um
1:42 provide the following disclaimer um this
1:45 webinar provides information and not
1:48 medical advice please note that the
1:50 information presented and discussed
1:52 might not apply to your own medical
1:53 situation and always discuss Medical
1:55 Treatments with your own healthcare
1:57 provider who knows your medical history
2:00 so tonight our presenter is Dr Alan
2:02 Kaplan he is a family physician
2:05 practicing in York Region Ontario and
2:07 has been a community pain consultant in
2:09 North Toronto and York Region for over
2:11 25 years including 15 years of pain
2:13 consultations in the Bramton Civic
2:16 Psychiatry program Dr Kaplan is the
2:19 regional Primary Care lead of the
2:21 central regional cancer program and
2:22 medical director of lhin pulmonary
2:25 Rehabilitation clinics he is also a
2:27 palet of Care Community physician and
2:30 was the previous head of the Pediatric
2:32 paliative program in York Region among
2:35 his many current and past distinctions
2:37 I’ve only noted a few Dr Kaplan is
2:40 chairperson of the family physician
2:42 Airways group of Canada an honorary
2:44 professor of primary care respiratory
2:47 Medicine of the observational and
2:48 pragmatic Research instit Institute in
2:51 Singapore he’s the past chairperson of
2:53 the respiratory section of the College
2:55 of family physicians of Canada a senate
2:58 member of the international primary care
3:00 respiratory group and vice president of
3:02 the respiratory Effectiveness group for
3:05 over 20 years Dr Kaplan has provided
3:07 continuing medical education programs to
3:09 teach clinicians how to safely provide
3:11 pain management in the
3:14 community so welcome everyone and uh
3:17 we’re really right across the country so
3:18 it’s uh late afternoon to uh to late in
3:21 the evening for for some of you now and
3:24 I’m going to talk about migraine and
3:25 sleep and you know is it the is it uh is
3:29 it the the cart the horse or is it both
3:31 that’s my little picture in the back
3:32 there so is it causing it or result of
3:34 it and uh many of you can feel like in
3:36 that right upper corner when you’re
3:37 lying you’re not able to sleep so we’ll
3:39 talk about that and many of you are also
3:41 familiar with and I’ll come back to this
3:42 picture on the left a little bit where
3:44 the nervous system where most of the
3:46 migraine comes from is the trial trial
3:48 nucleus which is inside the brain this
3:50 is the trigeminal nerve so we’ll talk
3:51 about some of these things and my my
3:54 conflicts I I am an adviser for a number
3:57 of different companies including asai
3:59 and adoria that makes certain drugs that
4:01 we talking about here as well as some of
4:02 the other drugs that were mentioned by
4:03 Kaye earlier so insomnia is it a problem
4:06 well if it wasn’t a problem you wouldn’t
4:07 be here so clearly it’s something that
4:09 you want to talk about up to 40% of
4:11 Canadians do experience problems with
4:12 sleep and 133% of people meet the
4:14 criteria for chronic insomnia which was
4:16 going on for a long time many never
4:18 actually talk to their doctors about it
4:20 so I hope those of you who are on the
4:22 call are going to take the advice of
4:23 having the conversation with your doctor
4:24 and take some of the ideas that I’ll
4:26 give you tonight to actually allow you
4:27 to do that um and oftentimes the Sleep
4:30 issue is related to something acute that
4:32 happens an emotional crisis but what we
4:34 do recognize and understand clearly is
4:36 that not sleeping makes everything else
4:38 worse especially in the pain world and
4:41 right until recently we’ve only had so
4:42 many choices when it comes from managing
4:44 insomnia in terms of pharmacologic
4:46 management so a lot of people are using
4:48 hypnotic medications and we’ll talk
4:49 about the pros and cons of
4:51 those now Beyond just the concept of
4:54 worsening other other diseases if you
4:56 can’t sleep it’s going to affect your
4:57 quality of life it’s going to make you
4:59 less productive during the day it’s
5:00 going to make you perhaps actually Mis
5:02 work as well and it especially if you’re
5:04 in a situation where you’re at risk or
5:06 even just driving increased risk of
5:08 injuries in accidents so this is a
5:10 terrifically important concept and
5:12 there’s a little bit more being talked
5:13 about it now but as I mentioned we
5:14 didn’t have a whole lot of treatments
5:15 for it so we’ve been using medications
5:18 to knock people out and we’ll talk about
5:19 the difference between being knocked out
5:21 and sleeping so pretty significant
5:23 long-term health risks for this and some
5:25 of you may relate to some of these
5:26 issues but mental health issues are a
5:28 big issue and we certainly see and for
5:30 those people who have substance use
5:31 disorder it’s a common thing goes along
5:33 as not being able to sleep
5:34 cardiovascular issues are a big problem
5:36 especially when there’s things like
5:37 obstructive sleep happiness there but
5:38 even just not sleeping at all increases
5:40 your risk of cardiovascular outcomes uh
5:43 when you don’t sleep you tend to eat
5:44 poorly it’s a it’s not a perfect
5:46 correlation but it tends to happen that
5:48 leads to weight gain which leads to
5:49 diabetes that’s there so these are all
5:51 there and what I’m going to talk about
5:53 of course is headache and pain is a very
5:55 significant long-term risk but headache
5:56 is not really discussed as much and this
5:58 is one of number slides from a slide
6:00 deck on on sleep overall and you can see
6:03 it’s not something that people
6:03 automatically think of when it turns to
6:06 issues of
6:08 insomnia now there’s some risk factors
6:10 overall for insomnia which
6:12 include the the being being female where
6:15 the risk is about 40% higher than in a
6:17 male in terms of not sleeping as we get
6:19 older it tends to get worse but also
6:21 recognize as we get older we don’t need
6:22 as much sleep so that’s a factor we have
6:24 to think about comorbid medical and
6:26 psychiatric conditions are big and
6:28 stressors and we all through stresses a
6:30 time and we’ve all had situations where
6:31 we can’t sleep because there’s things on
6:32 our mind and these are just two of the
6:34 obvious many stresses that can go on in
6:36 life um but hopefully that’s not going
6:38 to lead to long-term sleep issues but
6:40 unfortunately it can lead to that cycle
6:42 of not sleeping worrying about not
6:43 sleeping not being able to sleep and it
6:45 becomes a cycle of sleep becomes such a
6:46 large issue so sometimes it can be
6:48 something fairly not medically important
6:50 but it’s just just an emotional crisis
6:52 that occurs for a very good reason but
6:54 it leads to this chronic sleep issue now
6:57 what I want to just talk about here and
6:59 if any of these things become uh
7:00 appropriate for you to think about for
7:02 your reasons for not sleeping just think
7:04 about that so we know that there’s many
7:06 conditions that are going to affect your
7:07 sleep and some of them you know are
7:11 perhaps more obvious uh such as having
7:13 things like sleep apnea which is
7:14 obstruction and therefore when you try
7:16 to when you fall asleep deeper muscles
7:17 relax it blocks off your ear when you
7:19 wake up reflex or acid and heartburn
7:21 when people lay down and relax the acid
7:23 can come up metabolic issues like like
7:26 high sugar and high calcium both make
7:27 you urinate a lot and there you get up
7:29 to pee all night long uh we sort of see
7:31 this happening in conditions like
7:33 Parkinson’s and Alzheimer’s other
7:35 diseases of the brain obviously um the
7:38 issues of of of the urinary system for
7:41 men is the prostate gets bigger uh you
7:43 tend to not empty very well and
7:44 therefore urinate more often and for
7:46 women with a fallen bladder that can
7:47 also be an issue and of course menopause
7:49 leads to sleep issues as you know all by
7:51 itself mental illness is big and I’ve
7:54 discussed this already but I also want
7:55 to talk about psychotic disorders it’s
7:57 very interesting how many patients that
7:59 I have who have psychotic disorders who
8:01 actually have sleep issues with that as
8:02 well and it’s interesting if you can get
8:04 people sleeping better The psychosis
8:06 actually does reduce not all the way but
8:07 certainly improves it and then there’s a
8:10 whole list of medications that can end
8:11 up leading to affecting your sleep and
8:13 these are all very important medications
8:15 some of them we like to get rid of more
8:17 than others um be careful about
8:19 stimulants or over-the-counter
8:20 medications decongestants that we take
8:22 for Respiratory illnesses that can
8:24 actually uh lead to not sleeping
8:27 substances are a big thing of course
8:28 people tend to drink alcohol to go to
8:30 sleep that may help you initially get
8:32 knocked out but as you know it does not
8:34 keep you asleep I’ll talk about cannabis
8:35 later nicotine itself can actually be an
8:37 issue and then there’s medications we
8:39 take whether it’s heart medications
8:41 stimulants for ADD and things like that
8:43 certain anti-depressants can affect
8:45 sleep adversely uh Bronco dilators the
8:47 puffers you take for asthma the the blue
8:49 one that you Ed to open up your lung
8:50 could affect sleep and steroids but in
8:52 the form of oral corticosteroids that we
8:54 use that for more serious conditions but
8:56 actually that can do a lot of those
8:58 things it can affect cognition it can
9:00 affect mood it can affect sleep and can
9:02 also cause things like diabetes and
9:04 sugar to go up and therefore urinate
9:05 more so if any of these medications are
9:07 something you’re using uh something to
9:09 discuss with your doctors as a potential
9:11 ideology for you’re not
9:13 sleeping so that medication list so when
9:16 you you know if you are going to talk to
9:17 your physician after this about sleep
9:19 please remember to bring your
9:20 medications in with the doctor so we can
9:22 actually discuss this with you and if
9:23 anything I’ve said makes sense put a
9:25 little star beside it as you go in and
9:27 unfortunately it’s a b directional thing
9:29 between the illness and the insomnia
9:32 because it tends to perform a cycle so
9:34 if you’ve got pain and you don’t sleep
9:36 uh the pain therefore causes more
9:38 sensation in the brain where most pain
9:40 is felt and therefore that worsens the
9:41 sleep so you can see how this could be
9:42 an example of something that worsens it
9:44 worsens it so we need to treat the
9:46 underlying problem change the underlying
9:48 medications if possible deal with the
9:50 mental illness but we also have to treat
9:51 the sleep as part of this and sometimes
9:53 we consider sleep as part of the illness
9:55 but that isn’t always the way it works
9:56 and therefore we have to have success in
9:58 both edges
10:00 well I think you can all relate to this
10:01 thing is that we all have an insomnia
10:03 threshold something that’s going to stop
10:04 you from sleeping we may have some
10:06 predisposing factors but then something
10:08 happens that precipitates the reason for
10:10 not sleeping as we discussed earlier
10:12 with a stressful situation and then
10:14 something perpetuates that and then we
10:16 go from a situation where it’s temporary
10:18 to to longer lasting so we’ve got to
10:20 deal with all of these issues if in
10:21 terms of when you’re talking about
10:22 cognitive issues for sleep you have to
10:24 understand what caused it initially and
10:26 why you’re still having trouble with
10:27 sleeping now
10:29 so I’m going to I’m going to pull some a
10:32 bunch of Articles this is actually very
10:33 interesting talk to look up for because
10:35 there really isn’t a whole lot about
10:37 migraine and sleep as a combination so
10:39 so sleep to me is a huge problem in my
10:42 pain practice as well as my respiratory
10:43 practice and my family practice it’s a
10:45 huge issue but there’s not a whole lot
10:47 you know in terms of that terms of
10:49 migraine particularly in sleep so I went
10:50 back to the literature and found
10:52 actually going back to the 19th century
10:54 an association sleep and occurrence of
10:55 migraine was well established and in
10:58 1853 a a doctor Nam Romberg indicated
11:00 that a migraine can be stopped by sleep
11:02 and you all know that one of the
11:03 treatments for cute migraine was going
11:04 into a cool into a quiet dark room and
11:07 going to sleep and again this was found
11:10 again in 1873 showing the effect of
11:11 sleep on headache relief so people made
11:13 these observations way back in 19th
11:16 century saying that well sleep can be a
11:18 treatment for migraine but that’s not
11:20 the same as not sleeping being being an
11:22 issue for causing it so this sort of
11:25 looked at comorbid issues in terms of
11:26 causing headache and migraine Within
11:29 without Aura are intrinsically related
11:31 to sleep and really and I know migrant
11:33 cidate has issues with all kinds of
11:35 headache and I think that’s really going
11:36 to be important because they’re often
11:38 related to some degree chronic M
11:40 migraine chronic tension type migraine
11:42 medication overuse headache which is
11:43 whole other conversation we’ll talk
11:44 about later all can affect sleep and
11:47 that systemic dysfunction that occurs
11:49 because of those problems again going to
11:50 cause that cycle of issues so again the
11:53 cycle poor quality of Po or peration of
11:55 sleep could then be a trigger of the
11:57 migraine attack and it’s also quite
11:59 clear that people who have migraine tend
12:01 to have um who don’t sleep very well
12:03 have more frequent headache frequency
12:05 and then we also have to cope with our
12:07 migraines and going to sleep early to
12:09 try to relieve the migraine then throws
12:11 off your sleep study um not being able
12:13 to sleep because of the migraine throws
12:14 off your sleep your sleep situations as
12:16 well so you can understand how this
12:18 whole thing becomes uh bidirectional but
12:20 actually circal circular and cyclical
12:23 and causes things to get
12:24 worse now the data has shown here going
12:27 back as far as 2007
12:29 here that many Studies have shown that
12:30 people with a migraine have poor quality
12:32 of sleep than those who do not have
12:33 migraines and migraine prophylactic
12:35 treatment outside of actually preventing
12:37 the migraines which is why you take it
12:39 can actually improve sleep as well and
12:42 the the converse is true that migraine
12:44 is more likely to suffer from poor Sleep
12:46 Quality and therefore have fatigue and
12:48 that fatigue can actually be a trigger
12:50 in itself for the migraine so I’m just
12:52 showing you how many different ways we
12:53 end up with the same ending in addition
12:57 in terms of frequency of the migraine so
12:59 people have more frequent migraine tend
13:01 to have poor sleep and therefore worsen
13:02 the migraine prefer both with and
13:04 without Aura so again I’ll talk about
13:07 pharmacologic therapy and some non-farm
13:09 therapy but I just want to keep
13:11 mentioning the basics that things we
13:13 ingest be it alcohol which I mentioned
13:16 caffeine which affects sleep smoking all
13:18 of which affects sleep are all going to
13:20 affect the migraine as well they’re also
13:22 all potentially triggers for many people
13:24 so you look at that we have something
13:26 that’s a trigger something that can
13:27 affect sleep all leading to migraine you
13:30 know so the first step is understanding
13:32 those things that trigger you or can
13:33 affect your sleep and stopping them you
13:36 know and I can’t tell you how often
13:37 coffee is or caffeine is a common issue
13:40 for this I’ve talked about alcohol oradi
13:42 and cigarettes already but caffeine is a
13:44 huge huge issue and if you got a problem
13:46 with sleep then you should certainly not
13:48 have any caffeine after dinner time and
13:50 some people are so sensitive that you
13:51 have to even stop it during the day if
13:53 you’re going to stop caffeine make sure
13:55 you don’t stop it acutely you got to cut
13:56 the caffeine down SL you’re going to get
13:58 migraine are you’re going to get
13:59 headaches not migraine necessarily from
14:01 withdrawal of the caffeine so you want
14:02 to make sure that isn’t a trigger for
14:04 you so you have to cut the caffeine down
14:06 slowly so this is sort of that picture I
14:08 said and again hopefully you can relate
14:10 to the concept here if you have issues
14:13 with headaches then you may do many
14:15 things to cope with that you may take
14:17 you know you you may have issues with
14:20 medications you take which lead to
14:21 medication overuse if you’ve got
14:22 headaches your coping mechanisms May
14:25 because you don’t sleep very well may
14:26 lead to daytime naps and caffeine to
14:28 keep awake all of which can then lead to
14:30 the insomnia if you have headaches it
14:31 may lead to effects of the of the of the
14:34 of the Sleep physiology which I’ll talk
14:36 about now can affect sleep it can lead
14:38 to metabolically affecting your
14:39 melatonin levels in your brain which can
14:41 then also affect sleep but also affect
14:43 headaches and sleep is known and I’m
14:46 missing an error here The Chronic
14:48 insomnia needs to increase pain
14:50 sensitivity so all chronic pain and most
14:52 even acute pain is felt in the brain and
14:54 we really understand that concept of of
14:57 of of sleep leading to worsening pain
15:00 and that’s also true for headache and
15:02 that leads to that Central sensitivity
15:03 in the brain so so so things that
15:06 wouldn’t bother you as much bother you
15:08 more Therefore your triggers are going
15:09 to become more emphasized and therefore
15:11 that’s all there so hopefully this
15:13 picture sort of makes sense to you that
15:14 this is a very interrelated uh issue
15:16 which is really what I’m trying to
15:18 say now when we talk about sleep we talk
15:21 about the structural organization of
15:23 sleep there basically two types of sleep
15:25 non-rem sleep and REM sleep the rapid
15:28 eye move
15:29 sleep where if you watch someone sleep
15:30 you can see their eyes moving while
15:31 they’re sleeping and the non-rem Sleep
15:34 which is the Preparatory stages the REM
15:35 sleep is really what we want to have
15:37 more and more of if possible so as you
15:39 fall asleep we have the N1 stage of
15:41 sleep that’s the falling asleep very
15:43 light sleep it’s only about 5% as you
15:45 get a little bit deeper that’s the end
15:46 two stage and that’s a lot of our sleep
15:49 although it decreases later on in the
15:50 evening the stage three or the Deep
15:53 Sleep is called the slow wave sleep and
15:55 your brain waves settle down really
15:57 really important time for us for things
16:00 like healing of muscle and tissues for
16:02 improving our immune system for removing
16:04 metabolic waste fire lymphatic system
16:06 it’s about 20% of the sleep but you know
16:09 you know your mother who told you when
16:10 you’re younger go to sleep when you’re
16:11 sick because you need to get better by
16:13 sleeping is true this end this this slow
16:16 way sleep really allows you to heal
16:17 where REM sleep um you lose your muscle
16:20 tone so everything relax is again
16:22 important for muscle repair at heel it
16:24 does associate with Vivid dreaming so
16:26 people who don’t dream at all may not be
16:28 getting sleep one of the questions I ask
16:30 my patients when they have sleep apnea
16:32 if they don’t think it’s a problem I ask
16:33 them if they dream and it’s it’s
16:35 probably related to things like memory
16:37 consolidation emotional regulation and
16:39 executive function so therefore if you
16:41 don’t have REM sleep you can’t think and
16:43 you’re going to be emotionally
16:44 distraught and so on and you’re not
16:46 going to be able to remember things so
16:48 those might be things that relate to you
16:50 so this can be up to a quarter of your
16:52 total sleep all our sleep decreases with
16:54 age very important as I said earlier
16:56 that we we need less sleep as we get
16:58 older older but how we sleep is also
17:01 important so this gives you an idea
17:02 again you know that initially you don’t
17:04 have much REM sleep and your REM sleep
17:06 gets longer and longer as the night goes
17:08 on but if you don’t sleep for longer you
17:10 wake up frequently that REM sleep gets
17:11 interrupted and you have less REM sleep
17:14 so less of that relaxation so you can
17:16 see that it’s variable through the night
17:18 it comes and goes um but this is what
17:20 usually when we wake up and that’s why
17:22 people can often remember their dreams
17:23 because their REM sleep was just before
17:25 they woke up so that’s that’s an
17:26 interesting time so most of the time
17:28 about four to five Ram cycles per night
17:30 and again lengthen the latter part of
17:31 the night which is
17:33 important you’ve all heard the concept
17:35 of weekend migraine so here’s a
17:37 situation again where what’s the trigger
17:39 the trigger might be what you do on the
17:41 weekend as the picture in the corner but
17:42 it also related to sort of sleeping too
17:44 much which people don’t realize actually
17:46 if you sleep much more than you normally
17:48 do catching up on the weekend that can
17:50 trigger Migra of course sleep
17:51 deprivation is a very common trigger of
17:53 the migraine attack in the morning so
17:55 you know you’ve just finally had your
17:57 weekend off and then you wake up up with
17:58 a bad migraine on Saturday morning and
18:00 there goes your weekend which is
18:01 obviously very
18:03 miserable the other issue is that sleep
18:05 can lead to the conversion so one of one
18:08 of the most difficult um things I have
18:11 to treat is people with chronic migraine
18:12 you know where the migraine starts
18:14 happening you know many days a month or
18:16 almost even daily and we know that sleep
18:18 is one of the concepts there so one of
18:20 the first things I ask about is sleep in
18:22 those situations and that chronic
18:23 insomnia disorder may perpetuate that
18:25 chronic headache situation so you know
18:28 does the insomnia may come first and
18:29 then the transformation does the you
18:31 know migraine come first again card of
18:34 the horse not sure but what’s important
18:36 here is the inter relationship between
18:37 them now again how you then cope with
18:40 your migraine cope with your chronic
18:41 headache makes a difference in terms of
18:43 diet and stress that we’ve talked about
18:45 but either way these things perpetuate
18:47 each other leading to both headache and
18:49 insomnia my analogy here is a couple of
18:51 interlocking gears my picture so it
18:53 shows there that one leads to the other
18:55 which then goes back and leads to the
18:56 other again again that that cycle so
18:59 message here is we need to work about
19:00 sleep to improve our migraine on top of
19:02 everything
19:03 else now if I looked at the literature
19:05 about migraine and different kinds of
19:07 sleep so the common thing we’re talking
19:09 about is insomnia but there’s other
19:11 kinds of sleep disorders as well so I
19:12 thought I’d briefly touch on those for
19:14 us so insomnia is far away the most
19:17 common it’s defined as trouble falling
19:19 asleep or staying asleep or not having
19:21 enough sleep um despite adequate
19:24 opportunity to sleep with consequences
19:26 during the day you know being being
19:27 fatigued and having trouble functioning
19:29 and so on um looking at different trials
19:32 patients with migraine tend to have a
19:34 higher prevalence of insomnia than those
19:36 without headaches so interesting you see
19:38 the numbers it’s almost double in that
19:40 numbers we talked about the daytime
19:42 function that impairs and in add in
19:45 addition if you have migraine but you
19:47 also have sleep issues we talked about
19:49 that central pain sensitivity you
19:50 actually get worsening pain more
19:52 frequency attacks and more likely to
19:54 cify Chron chrony or make long
19:58 um your headaches or have them more days
20:00 more days in a month so interesting
20:03 again these things are related and
20:04 therefore we have to look at
20:06 both this article by Kim also looked at
20:09 the comparison of headache type in those
20:11 on the left who had insomnia and those
20:12 on the right who did not have insomnia
20:14 and you can see that the hatch deck is
20:16 are non-headache uh the the squares are
20:19 those with non-migraine headache so a
20:21 lot more non-migraine headache inomics
20:24 and a lot more the top do ox’s migraine
20:26 and a lot more of migraine headaches as
20:28 well well so headache type is certainly
20:32 non-migraine more significant that but
20:34 also the migraine so overall more
20:36 headaches Al together and then if I look
20:38 at the prevalence of insomnia uh the
20:40 prevalence of the types of headaches in
20:42 patients with insomnia looking at from
20:44 the other direction migraine is the most
20:46 common kinds if you have insomnia
20:48 followed by about half of that with
20:50 non-migraine and a group of course with
20:52 non- headaches as well so you’re seeing
20:54 those relationships as well now
20:56 obstructor sleep apnia is a fairly
20:58 common situation that sometimes doesn’t
21:00 get diagnosed because what happens is as
21:02 you fall asleep and getting into that
21:03 REM sleep especially where your tone
21:06 relaxes and you have things like a thick
21:08 and glaus and I think I got a picture up
21:09 there on the far right we get an idea
21:11 everything falls back and that leads to
21:13 the airway blocking so that therefore
21:16 leads you to not get into deep sleep
21:18 you’re waking frequently that leaves you
21:19 being tired the classic symptom course
21:22 is the bad snoring and the and and if
21:24 your partner notices apnea which means
21:26 you stop breathing entirely
21:28 that means it’s that much worse so it
21:30 prevents sleep it can wakes you up and
21:32 of course morning headaches are very
21:35 common uh with obstructive sleep apneia
21:37 because you haven’t slept and you’ve
21:38 been sort of choking all night long so
21:41 migraine headaches interestingly are not
21:42 more common with people obstructive
21:44 sleep
21:45 apnea so but they have certainly there
21:48 so what’s important here is that
21:50 migraine and sleep apnea are two
21:52 separate things but again if you’re not
21:53 sleeping no matter the cause it’s going
21:55 to worsen your migraine the other very
21:57 important thing about obstructive sleep
21:59 apnea is that if you have it and you
22:01 don’t treat it It’s associated with very
22:03 bad cardiovascular outcomes causing
22:04 hypertension Atri fibrillation coronary
22:06 artery disease so if you have any of
22:08 these symptoms this is on our our our
22:11 Airway group site screening from Str to
22:12 sleep AP it’s called The stopbang Tool
22:15 so if you snore you’re tired during the
22:16 day someone has seen you not not breathe
22:20 you’re being treated for hypertension
22:22 and physically you’re on the heavy side
22:24 you’re over the age of 50 you got a very
22:26 thick neck over 40 cm this is more
22:28 common in men and any three of those
22:29 seven means you’re high risk and those
22:31 people should be sent for a sleep study
22:33 which is a test you can do both both in
22:35 a Sleep Clinic and now there’s remote
22:36 ones you can do as well I know access
22:38 for this is difficult across the country
22:40 but again if you think you have sleep
22:42 apnea discuss it with your doctor and
22:44 you need to treat it and that’s of
22:45 course using CPAP or dental devices but
22:47 sleap is the far away the
22:49 best parasomnias are category sleep out
22:53 defined as undesired Behavior so the
22:55 class think is going to be things like
22:56 sleepwalking uh and teeth grinding or
22:59 bad experiential phenomena like
23:02 nightmares so um somnambulism is
23:05 sleepwalking has been associated with
23:06 migraine intering and there’s a higher
23:08 rate of people sleepwalking and people
23:10 with migraine with aura now children is
23:12 usually where sleep walking generally
23:14 occurs so that’s interesting and I I’ll
23:17 start talking about mechanisms here a
23:18 little bit where the serotonergic
23:20 pathway may be there serotonin as you
23:22 know is in some of the anti-depressants
23:23 we use which may explain why some of
23:25 these medicines work so we’ll come back
23:27 to medicines in bit but you can see here
23:29 that these this is certainly associated
23:31 with migraine restless leg syndrome
23:33 where your legs are sort of shaky and
23:35 jumpy as you try to fall asleep is
23:36 pretty common up to 10% of the
23:38 population but look at the number in
23:40 migraine it’s up to 40 almost 40% so
23:43 much more frequent to have restless leg
23:44 syndrome in people with migraine versus
23:47 versus normal and versus attention
23:48 headache they also have more likely to
23:51 have bad symptoms of photophobia
23:53 phonophobia vertigo I noticed that as
23:56 Kaye said you’ve got a vertigo and and
23:57 migraine uh talk coming up so that
24:00 hopefully they’ll talk about that as
24:01 well but tinitus as well which goes
24:03 along with the inner ear dysfunction
24:04 dizziness and even neck pain so these
24:06 are all related now in Parkinson’s
24:09 disease um migraines is associated with
24:12 sleep disturbance uh overall while
24:16 before you develop it once you develop
24:18 Parkinson’s and the diagnosis been made
24:20 headache and migrant severity actually
24:21 goes down and it’s interesting that the
24:25 major treatment we use for restus leg
24:27 syndrome is mirex which also has
24:29 activity in in Parkinson’s so the brain
24:32 is related in many different ways and
24:33 here’s just another example why other
24:35 chemical relationships can happen there
24:37 for the brain sleep and migraine bruxism
24:40 means grinding many of you are familiar
24:41 with this it’s bad for your teeth but
24:43 it’s also really bad for your tempor
24:44 mandibular joint if you look at the
24:46 picture in the upper corner you can see
24:47 the TM joint then leads you know has
24:49 these these mass or muscles these big
24:51 huge muscles that you chew with and can
24:52 go into spasm because of that and then
24:54 the muscles um have nerves going through
24:56 them that can that cause pain in the
24:57 nerves NES all of which then goes back
24:59 to the terminal nucleus as we talked
25:00 about and lead to the migraine so
25:03 therefore what happens is that if you
25:04 got TMJ disease uh then you want to
25:07 think about treating that as well which
25:09 includes bio feedback and night guards
25:11 and very rarely can even include surgery
25:13 although that doesn’t get done very
25:14 often because it’s quite the surgery but
25:16 again if you grind your teeth and your
25:18 partner is complaining you grind your
25:20 teeth or you recognize yourself discuss
25:22 it with your dentist and get a night
25:24 guard it can save your teeth in many
25:25 dental bills but also will decrease your
25:27 migraine into your total
25:29 headaches there’s a picture of a night
25:31 guard that you wear at night time
25:32 there’s many different
25:33 kinds now narcolepsy uh is a condition
25:36 that affects the brain’s ability to
25:37 control sleep wake Cycles so actually
25:39 people with naria they feel great when
25:41 they wake up in the morning and then
25:42 they get more and more sleepy as the day
25:43 goes on so narcolepsy mgan may coinx but
25:47 it’s not it’s not clear uh they have
25:49 other headaches as well but not just
25:51 migraine and there is some antigen tests
25:53 so in the future we’re going to be able
25:54 to do testings for both Gene testing and
25:56 antigenic testing right now we’re not
25:58 there yet I want to introduce the ere
26:00 exergic system which is something that’s
26:02 a little bit newer and we’ll talk about
26:04 that but it has a relationship between
26:06 narcolepsy and migraine and these two
26:08 neuropeptides Rex and a and b are
26:10 synthesized in the hypothalamus and
26:12 they’re involved in things that we found
26:14 interesting wakefulness automatic
26:15 regulation hormone secretion they have
26:17 different receptors that have different
26:19 levels and periods of weakeness and
26:21 basically you know ereen makes you more
26:23 awake they strengthen the neuropath
26:26 networks of the hypothalamus to to imp
26:28 to to stimulate wake wakefulness and
26:31 also change the the the the cycles of
26:34 sleep and if you have a dysfunction in
26:36 this system and your hypothalamus then
26:39 it it may be related to narcolepsy so if
26:41 you don’t have enough orex and you’re
26:42 less awake so this is the opposite of
26:45 course of of insomnia where you can’t
26:47 where you can’t where you can’t fall
26:49 asleep but it’s got effects in different
26:51 parts of sleep as
26:52 well so we’ve been trying to figure out
26:55 why for a long time in the medical
26:57 community and we’ve been trying to look
26:59 at different biochemical mediators some
27:01 of which I’ve mentioned they’re involved
27:02 both migraine sleep so what is the
27:04 relationship between these things and of
27:05 course A lot of these medic a lot of
27:07 medications that you’ve heard of work on
27:09 these these
27:10 classes and again coming back to the
27:12 concept of of of that Central
27:14 sensitivity that occurs and the
27:16 different pain uh threshold so normally
27:18 when you have a when you have a pain
27:20 issue the pain as you can see on the
27:22 right here comes from wherever it comes
27:24 go through the dorsal Horn of the spinal
27:26 cord and then goes up to the brain where
27:28 the brain then deals with it thinks
27:30 doesn’t think about it deals with it and
27:31 sends inhibitory Pathways down so the
27:34 example is if you stub your toe you stub
27:36 your toe all you know first of all is
27:38 that you got this blinding pain that’s
27:39 that first mention because it’s a
27:40 warning system and then you realize it’s
27:43 your it’s your toe that hurts because
27:45 that’s the first descending function and
27:47 then you realize okay it’s my toe it’s
27:49 not that bad it’s still attached and
27:51 that’s the second inhibitory pathway and
27:53 many of the conditions that lead to
27:55 chronic pain decrease those inhibitory
27:57 path Pathways and the medications we Ed
27:59 trying to stimulate them now when it
28:01 comes to migraine we talk about the
28:03 trigeminovascular system and there’s a
28:05 whole imbalance of of nerves at the dura
28:08 brain stem cortex and subcortical
28:10 regions in addition up there in the
28:12 brain the pineal gland as you know
28:13 secretes melatonin which is going to
28:15 affect sleep you all you’ve all heard
28:16 taking melatonin for sleep and we we
28:19 sort of measured these different um
28:22 chemicals in the brain and that
28:24 melatonin might level if it’s low might
28:27 also um make you wake up from Rapid Eye
28:30 moving sleep and therefore lead you with
28:31 a headache so I’m telling you all this
28:34 um and I know most here are not are not
28:37 Healthcare practitioners but even as
28:39 people suffering with migraine it’s
28:41 important to know that there’s real real
28:43 mechanisms of pain here that occur and
28:45 there’s reasons why this happens and the
28:48 important thing is therefore there’s
28:49 things we can do about it and that’s
28:50 what I want you to take away from that
28:51 as well so I did this backwards so here
28:54 is a whole bunch of neurotransmitters
28:56 that can be involved and I’ve mentioned
28:59 serotonin and dopamine gabin or
29:01 adrenaline and here’s ere rexin and some
29:03 of these medications might be familiar
29:05 to you buproprion different
29:07 anti-depressants uh amitryptiline
29:09 norpine or medications we use to
29:11 prophylax for migraine symbols is a
29:13 another anti pressent we use for pain
29:15 Gabapentin AA um have have been used for
29:18 for migraine prevention for chronic
29:20 headache prevention for chronic pain and
29:22 I’ll introduce this new class of drugs
29:23 the urin antagonists for which right now
29:26 in Canada we just have one Deo cuig is
29:28 in the states um so we’ll talk about Deo
29:31 because we don’t have it available in
29:33 Canada
29:34 yet so the mechanism here as you know
29:37 migraine occurs due to the stimulation
29:38 of the trigeminovascular system so you
29:41 know we get this throbbing headache but
29:43 it starts in the nervous system and the
29:45 nervous system then leads to the blood
29:46 vessel dilating and that causes that
29:48 throbbing headache a lot of the
29:49 medicines we use over time is trying to
29:51 keep the blood vessel from throbbing now
29:53 we’re using medications aiming at the
29:54 nerve because it’s those nerves really
29:56 that are causing the whole thing and
29:57 they release this chemical mediator
30:00 called
30:00 cgrp and this cgrp is really really
30:03 important because we now have cgrp
30:05 Inhibitors that can block this and these
30:08 are injections that anywhere from once a
30:09 month to every 3 months there’s now
30:12 actually a pill form of this as well and
30:14 these medications are are amazing when
30:17 it comes to migraine prevention but
30:19 they’re crazy expensive as all biologics
30:21 are but they work well now this
30:24 disregulation of the hypothalamus and
30:26 brain stem are these pathologic methods
30:28 and again they then lead to the ginal
30:30 nerve and again but the hypothalamus and
30:32 brain stem are related to sleep so brain
30:34 stem especially so you can see that the
30:37 brain is related to all this DOP mean as
30:39 well and we talked about ere rexin so
30:42 this again come back to the Rex energic
30:44 system because this is the new kid on
30:47 the Block when it comes to sleep so I
30:48 want us to understand that so we talked
30:50 about that rexen nerves are in the
30:52 hypothalamus and they’re related to
30:55 sleep wakefulness but also migraine they
30:58 fire in wakeful wakeful States so
31:01 therefore if you disrupt the your oxic
31:03 signal it causes
31:05 sleepiness okay so it can affect monam
31:07 activity pain modulation but also can
31:10 affect trigeminal vascular tone which I
31:12 said is the central thing so is it
31:15 perhaps surprising that when we get
31:17 triggers like stress and fatigue sleep
31:19 deprivation or poor sleep it activates
31:21 hypothalamus and affects the urin system
31:24 increasing the urin levels and therefore
31:26 preventing sleep so rexen leads you to
31:28 be
31:30 awake so this is a mouse model and what
31:33 they saw here and again this is you know
31:35 that’s a bit complicated but I’m just
31:36 showing you that biochemically this has
31:38 been proven um this the group on the far
31:41 left are just treated with there’s a
31:43 control group this middle group here was
31:45 given an injection of something called
31:46 CFA which stimulates orexin and this
31:49 group here had the CFA plus the the
31:52 orexin receptor antagonist and you can
31:54 see over time with and they all they all
31:56 will trigger with a stimulus so the
31:58 ereen um levels all increased to all
32:02 three but you can see the Dora group the
32:04 group that H Rex antagonist had much
32:06 less overall than this group that did
32:08 not have it so what happens here that
32:11 with a stimulation you’re getting you’re
32:13 getting the the levels of the erection
32:16 rise but you can block it and have it
32:18 the similar to the people or excuse me
32:22 the animals that that did not have any
32:23 treatment at all so the concept here is
32:26 that um if we if these are all macres
32:29 being Lev being measured in the
32:31 trigeminal gangion which is really the
32:33 key point that we talked about for
32:34 migraine now overall ereon and pain this
32:37 is a an abstract this is a post delay
32:40 that presented in a number of places and
32:42 they really looked in this initial group
32:44 of patients with ere rexin at pain
32:46 overall and did ereen antagonist
32:48 actually decrease pain and what you can
32:50 see it was a small study but you can see
32:52 the number of people um whose pain
32:54 scores decreased increased as we had the
32:58 use of the erex antagonist and this is
33:01 people with really bad really worse
33:02 problems with pain and going down from a
33:05 score from 3 to one happened in most
33:07 most of the patients overall so again
33:10 erex can help pain so what am I going to
33:14 do with all this for you then well um
33:16 we’ve talked about avoiding triggers and
33:17 avoiding certain medicines we’ve talked
33:19 about um how bad the migraine is which
33:23 you’re all familiar with measuring of
33:25 things like hit six scores and things
33:26 like that you probably do with your
33:27 doctor and pain scores but we’re also
33:30 going to measure the severity of insulin
33:31 I’m going to show you prophylactic
33:33 medications and make sure it’s one
33:35 that’s going to help sleep as well
33:37 preferably uh we want to sleep but just
33:39 plain sedatives which are not Far and
33:41 Away the number one used drug used for
33:43 Sleep unfortunately we should talk about
33:44 the benzo diazines and the Zed drugs
33:47 because actually sedatives can worsen
33:49 I’m going talk about sleep hygiene I’m
33:51 gonna talk about this newer uh class of
33:54 drugs which might work better but I
33:55 don’t have a whole lot of human data on
33:58 rexen levels as I showed you um but
34:00 there certainly is some there certainly
34:02 is some some passive observational
34:05 data so this is a tool your doctor May
34:08 provide for you or as clinicians you’re
34:10 going to provide to your patients who
34:12 have sleep issues called the insomnia s
34:14 index it’s one of many tools for sleep
34:17 but I find it to be actually quite easy
34:18 to use and it’s quite demonstrative to
34:20 to treatment so trouble falling asleep
34:23 trouble staying asleep waking up too
34:25 early are you satisfied with your sleep
34:26 s do sleep symptoms inter sleep loss
34:29 symptoms interfere with your daily
34:30 function and affect your quality of life
34:32 and are you worried about it you can see
34:33 it’s a like cart from zero to four and
34:35 you can add up those scores so gives you
34:37 different levels of insomnia and it’s a
34:39 really good tool in primary care to
34:42 actually measure sleep and you can then
34:44 measure the efficacy of the treatments
34:46 you’re giving so something may knock you
34:48 up and you may not stay asleep okay you
34:50 still May wake up too early okay you may
34:52 be sleep sleep sleeping with a benzo
34:54 drug but you may not be drowsy may be
34:56 drowsy next day not happy with it so it
34:58 can give you a good measurement of how
34:59 your medicines are working now we talked
35:01 a little bit about some of the
35:02 medications that can worsen sleep and
35:05 I’ve talked about those already in terms
35:07 of um metabolic issues with it but I
35:11 want to point out that also we can get
35:13 rebound headaches now rebound headache
35:15 means that your body recognizes these
35:18 chemicals you’ve been taking on a
35:20 regular basis and therefore you have a
35:22 bit of withdrawal from them and part of
35:24 the withdrawal is not sleeping and these
35:26 can be some of the most difficult
35:28 headaches to treat any of you that
35:30 suffer with that will understand that so
35:32 if you use a painkiller every day
35:35 aspirin ibuprofen napasin these are
35:37 anti-inflammatories acetaminophen
35:39 certainly drugs with narcotics um that
35:42 can then lead because of the fall and
35:45 the level of it for you to wake up and
35:46 have sleep issues even trip Tans which
35:49 we rely on for acute migraine treatment
35:51 you shouldn’t use too many in a month
35:54 and I try to keep it to no more than
35:55 three a day and no more than 12 a month
35:57 and even 12 is for me is too high
36:00 caffeine medications well Tylenol with
36:02 Codine has caffeine Tylenol number one
36:04 or even just some some of the plain
36:06 Tylenol have caffeine and what the what
36:08 the makers did years ago is they
36:09 recognized that Codine made people
36:10 sleepy so they put the they put the
36:13 caffeine in with the Codine and the
36:14 Tylenol so it wouldn’t get drowsy from
36:16 the medication but caffeine’s bad for
36:18 your sleep so don’t do that when it
36:21 comes to treatment I’ll talk about
36:23 non-pharmacologic first some of you have
36:25 had the ability to go to cognitive
36:27 behavioral therapy for insomnia
36:29 different techniques involving sleep
36:30 restriction relaxation training and
36:32 education it can be online it can be in
36:34 person it can be self-guided it’s
36:36 tremendous if you can get it um but
36:38 there’s unfortunately a Pity of places
36:39 in Canada where you can get it now you
36:42 can use pharmacologic treatment along
36:43 with it uh if you can get cbti please do
36:46 this it may be enough without
36:48 medications while you’re waiting for it
36:50 or in addition to it you may need
36:51 medications and we’ll talk about that
36:54 but before we talk about medicines I
36:55 want to talk about the concept of sleep
36:57 hygiene now if you’re not doing these
37:00 things please do all right so consistent
37:05 schedule avoiding bright light uh at
37:08 night but increasing it during the day
37:11 okay daily routine don’t do things late
37:14 at night that’s going to wake you up
37:16 don’t do things like an exercise then uh
37:19 stay off your electronic devices for
37:21 half an hour you know using your bed for
37:23 sleep and sex now sleep is an act sex is
37:25 an activity I get it but usually you’re
37:27 tired afterwards but get that routine
37:29 going maybe a warm bath before you go to
37:31 bed that dark quiet room not too hot not
37:35 too cool a cool temperature so you’re
37:36 not sweating or you’re not shivering
37:39 avoid napping during the day avoid
37:41 caffeine nicotine or stimulant avoid
37:43 alcohol at bedtime avoid bright light at
37:45 night avoid exercising late at night
37:47 avoid a heavy meal before you go to bed
37:49 you right and what about the clock now
37:53 anyone who’s ever had trouble with sleep
37:54 has a clock beside their bed and they
37:56 wake up and look at what time it is and
37:57 they get worried about the fact they’re
37:59 not sleeping and that leads to a cycle
38:01 in itself the best thing really is to
38:03 get rid of that clock and I know it’s
38:04 really really hard to do but try to get
38:07 rid of that clock and stay away from a
38:09 lot of fluid at night because what goes
38:11 in has to go out so if you’re going to
38:12 drink a lot you’re gonna have to get up
38:14 and pass it out John Crosby is a a a
38:17 retired family doctor from Cambridge and
38:19 he he does a bunch of blogs so I really
38:21 like this because it reinforces this
38:23 this goes out to Physicians as part of
38:25 the medical post so here’s like this
38:27 reinforce this right so no caffeine ever
38:31 and I like the fact he highlighted Red
38:33 Bull Cola chocolate also Mountain Dew
38:37 has a caffeinated version um cool room
38:41 maybe maybe some white noise like a fan
38:44 uh that can work ear earplugs may work
38:46 if your partner wakes you up uh again no
38:49 napping go for a walk instead get a good
38:51 bed get a good mattress you spend a
38:53 third of your life in your bed so that’s
38:55 relevant go to to bed the same time
38:57 every night now what happens and this
38:59 has happened to all of you you’ve woken
39:00 up in the middle of night and You’
39:02 thought about something you really have
39:03 to do tomorrow and then you sit there
39:05 and think about it and think about it
39:06 and you try to say well I have to
39:07 remember this tomorrow well first of all
39:09 you’re good chance you’re going to
39:10 forget so do what I do if you like I
39:13 have my phone by my bed it’s also my
39:15 alarm so I actually take my phone out
39:17 and I send myself an email okay if you
39:19 don’t have a phone get a piece of paper
39:21 and a pencil and write down the note you
39:22 can get it in the morning it’s amazing
39:24 once you stop thinking about what you
39:26 have to do tomorrow you can turn it off
39:29 okay if you can’t sleep for a period of
39:31 time okay this is part of cbti don’t
39:33 just lie there go do something else read
39:36 a book but make sure it’s a boring book
39:37 drink some more milk but not too much
39:40 have that bath but don’t fall asleep in
39:41 the bathtub you get it our alarm clock
39:43 we talked about we talked about screens
39:45 so you can see all this stuff is very
39:48 relevant and very very important this is
39:51 a really interesting trial well they
39:52 they took people with a BMI who are a
39:54 bit heavier with BMI above 25 they
39:56 weren’t sleeping and they actually the
39:58 only intervention they did was sleep
40:00 hygiene light bedtime routine
40:02 Electronics get some goals more exercise
40:04 less caffeine and they slept more an
40:07 hour and a half more but they also lost
40:09 150 calories per day wow so just because
40:13 of sleep hygiene they lost a pound every
40:15 every two weeks and they felt much
40:17 better their energy level was better so
40:19 sleep hygiene is not just something to
40:22 poo poo it’s something to really take
40:24 seriously okay what medications do we
40:26 have currently approved for the
40:27 treatment of insomnia well we have
40:29 benzodiazapines certain benzoin not all
40:32 of them okay so the classic benzo you’re
40:34 all familiar with of course it’s going
40:35 to be valium or deip Pam it’s not
40:37 included in this list non- benzo
40:39 receptor antis or Zed drugs they work on
40:42 on these receptors and therefore Works
40:44 somewhat like benzo aines they work on
40:45 Gaba receptors as well some of these
40:47 medications are familiar to you um
40:49 sedating tricyclics like doyin or
40:52 silenor is the is a brand name for it’s
40:54 lowd do doyin and I’m going to come back
40:56 can talk about Lumber exent which is a
40:57 different class of drug so these ones
41:00 are gab energic and you can see that
41:02 they all help with sleep onet they’re
41:05 variable help for Sleep maintenance
41:07 triazolam is not it’s a very short
41:09 acting one do not take that if you’re on
41:11 that and do not take Al praam if you’re
41:12 on that but they’re all all recommended
41:16 excuse me for only seven to 10 days so
41:19 these are not indicated for longterm
41:21 they’re indicated for that shortterm
41:23 acute problem a grief problem a stress
41:26 problem we need them for short term but
41:29 unfortunately this gets started and they
41:30 work and people come back to the doctor
41:32 and say I want them and because we
41:33 haven’t had whole lot of Alternatives
41:35 this is something that people end up for
41:36 long terms and it’s really really hard
41:38 to get people off these medications when
41:40 they’ve been on for a long time because
41:41 your body gets used to them and
41:43 therefore withdrawal is a big issue so
41:45 again if you’re looking at the side
41:46 effects of benzos and Zed drugs you can
41:49 see the sedation but memory deficits
41:51 motor def tolerance which we talked
41:53 about the rebound insomnia some complex
41:56 sleep behaviors which fortunately is not
41:58 very common the tricyclics can lead to
42:00 anticholinergic effects like dry mouth
42:03 they can lead to weight gain right and
42:06 erex antagonist can lead to some
42:07 sedation we’ll talk about that but you
42:09 can see the Fairly significant things
42:10 and if any of you have taken these
42:11 medications you’re familiar with these
42:13 side effects so when it comes to off
42:18 label drugs because many of the drugs
42:19 are used off Lael for insomnia so I
42:21 talked about first about the ones
42:22 actually have an approval so the other
42:24 benid aines again same side effects
42:27 mapine or rron is an anti-depressant
42:29 that’s very sedating so it’s actually
42:32 very effective to knock people out of
42:33 night but it causes daytime station and
42:35 dizziness and a lot of weight gain
42:37 trazodone is a very common drug used for
42:40 this desel is the other name for it
42:43 again anticholinergic effects so dry
42:45 mouth orthostatic hypotension as can
42:48 amitryptiline nortryptiline which gets
42:49 used a lot uh used a lot also because
42:52 it’s also migraine prophylactic drugs
42:54 the atypical antis psychotic prodcts are
42:56 being used more and more uh cakil copine
42:59 is quite a sedating one so it knocks
43:01 people out but again leads to daytime
43:03 sedation and leads to a lot of weight
43:04 gain so be careful of that and the gabip
43:06 penin pregablin or Lyrica that I talked
43:09 about earlier can also lead to that
43:10 daytime sedation and weight gain so you
43:12 can see these drugs get used and they
43:14 may be effective to knock people out but
43:16 their effect at sleep is another matter
43:18 now I get asked about cannabis a lot and
43:21 cannabis certainly has some evidence for
43:23 sleep but especially in people who have
43:25 other psychiatric condition is mostly
43:27 postraumatic stress disorder that’s
43:28 where most of the data is and a little
43:30 bit in chronic pain and quite a bit
43:32 actually for spasticity multiple
43:33 sclerosis it makes you sleepy by
43:35 suppressing arousal and increasing that
43:37 sleep promoting adenosine which is one
43:39 of those chemicals that I forgot to
43:41 highlight earlier uh you should never
43:43 inhale this stuff in putting best stuff
43:45 into your lungs is bad for your lungs
43:47 remember I have a respiratory hat as
43:48 well as kayia talked about please don’t
43:50 use it this way if you’re going to use
43:51 it use it as oils and the amount of THD
43:55 is important so little bit of THC can
43:57 help for sleep but a lot worse than
43:59 sleep right it causes a whole whole
44:01 bunch of other things as well so again
44:03 if you’re going to use it not very much
44:05 of it for its effect if you’re going to
44:07 buy it off you know on your local corner
44:09 there’s not much evidence for from
44:11 medical cannabis and migraine um it may
44:14 reduce monthly migraine headaches uh and
44:16 there is some some show that it actually
44:18 can abort migraines in 11.6% of users so
44:21 that’s one out of eight or nine so
44:23 that’s not really a great uh great
44:25 number but if you’ve used it
44:27 successfully fine I would tend to use
44:28 CBD rather than THC for a bard of
44:30 treatment the C the THC is going to make
44:33 you sedated and hungry so you all know
44:35 the negative effects this came right off
44:37 the government of Canada site confus so
44:39 I’m not making it up confusion
44:41 sleepiness trouble to remember
44:43 concentrate pay attention react quickly
44:44 and to learn especially in those who are
44:46 young it can lead to anxiety fear and
44:48 actually Frank psychosis one of my jobs
44:51 working at a Psychiatry unit we would
44:53 admit someone every day with the effects
44:55 of cannabis causing psychosis again
44:57 addiction memory concentration IQ and
45:00 there’s pretty good evidence that
45:01 childhood use of THC actually affects
45:04 long-term intelligence and ability to do
45:06 that so again I’m not sure how old
45:08 anyone is on on probably probably not so
45:11 young but if you’re using cannabis and
45:12 you’re not your brain isn’t full grown
45:14 you’re doing yourself harm you’re doing
45:16 your brain harm and you’re not going to
45:17 gain that back as you get older so
45:19 please don’t do that so I want to then
45:22 move on to a real change in Paradigm of
45:23 sleep treatment and this insomnia is no
45:27 longer ceas of not falling asleep but
45:29 because of you’re too awake we’ve talked
45:31 about the ereon signaling that caus you
45:32 to be too awake and erex an antagonist
45:35 will therefore dampen that excessive
45:36 wakefulness so that’s the new treatment
45:38 Paradigm that we’re talking about so the
45:40 concept here is normally when you
45:43 sleep your sleep switches on and your
45:45 wake switches off um but you know during
45:48 the day it’s the opposite your your your
45:50 switch sleep switch is off and your day
45:52 and your and your wake switch is is
45:55 going to be on if you have insomnia then
45:57 your wake switch is still on even at
45:59 night time so what we want to try to do
46:01 is we want to keep your it keep your
46:04 sleep switch on and your and your wake
46:06 switch off when you take something
46:08 that’s SED sedative then while your
46:11 sleep switch is still on your wake
46:13 switch is on but now you’re also having
46:16 some sedation during the day and your
46:18 sleep switch is partly on during the day
46:19 that’s no good so the rexen antagonist
46:22 what they do is during the day your
46:25 sleep switch is off and your wake switch
46:27 is on and that revers is at night where
46:29 your sleep switch is on and now your
46:31 your wake switch is now turned off with
46:33 this drug so that’s the that’s the
46:35 concept of how this drug works and I’m
46:37 spending some time on this because I was
46:39 particularly asked to talk about new
46:41 treatments for sleep because I
46:42 understand you guys are concerned of
46:44 what you have and rightfully so overall
46:47 so a very little bit about data there’s
46:48 a couple of studies one’s a one-month
46:50 trial one’s a six-month trial with a
46:52 six-month extension looking at different
46:54 doses of lumbera accent which is the
46:56 name for davigo the first one compared
46:58 to zerm one of his head drugs so again
47:00 looking at this if you’re looking at the
47:02 Sunrise one the one month trial and you
47:04 compare the two different doses of of
47:06 the dgo lber xent you certainly had
47:09 trouble had Improvement in sleep on at
47:11 the last to the 30 days and if I go to
47:13 sleep to six month same thing
47:16 significant Improvement in how long it
47:18 takes you to fall a sleep compared to
47:21 Placebo but in this arm it’s comparing
47:24 it to to the Zed drug as well so it’s
47:27 it’s better than that um sorry the green
47:29 line here is is the zum The Zed drug so
47:32 both doses of the lumber accent were
47:33 better than the Zed drug so less than 25
47:37 minutes for most which seems like a very
47:38 long time but if you’re chronic insomnia
47:40 you’d be happy with that now this
47:42 Improvement in sleep onset was sustained
47:44 across the extension period as well so
47:47 one of the interesting thing about this
47:48 drug and I talked about the seven to 10
47:50 10 days indication for Zed drugs and
47:53 many these other drugs if they have an
47:54 indication at all this drug works and
47:56 keeps on working for the full year which
47:58 is the extent of this trial so there’s
48:00 no evidence of tolerance or dependence
48:02 occurring with this drug and again both
48:04 drugs were
48:06 effective now in terms of wake after
48:08 sleep onset again we’re seeing Placebo
48:10 here the two doses of the lumber xan you
48:13 can see that how long it takes you to
48:15 fall asleep uh how long it takes you to
48:17 stay asleep or therefore how long it
48:19 takes you to wake up after fall asleep
48:20 is is much improved with Lumber X and
48:23 again persists over the year
48:26 so Total Sleep Time the same kind of
48:29 picture okay both improved uh compared
48:32 to the Zed drug certainly compared to
48:34 Placebo and if you look at it for the
48:36 course of the six months it gets better
48:38 and it continues to improve over the
48:40 course of that time for the total sleep
48:42 time really important for that now side
48:45 effects are what all of us are concerned
48:47 about medications so they did some
48:48 really interesting things they sort of
48:50 measured your your your posture and your
48:53 and your stability uh both during the
48:55 day and in the middle of the night and
48:57 they found they put you on this
48:58 complicated machine and they had four
48:59 treatments a zed drug Placebo and the
49:01 two doses Lumber xand and they found
49:05 that in the middle of the night there
49:07 was some swaying so while this drug is
49:09 very active there’s going to be a
49:11 swaying still not as much as Z drug but
49:13 it’s there but by morning because this
49:15 drug is pretty well gone by sort of
49:17 eight hours in the morning um then
49:19 you’re okay in the morning similarly
49:21 they did driving tests and they did
49:23 driving test and you know this so
49:24 interesting nine hours after the dose he
49:26 did a 100 kilometer drive after day two
49:28 and day nine of the medication and they
49:30 compared the amount of the amount of
49:33 difference in terms of how much you
49:34 swayed around the road now some of you
49:36 may sway anyhow but ideally you’d like
49:37 to be able to stick in your lane right
49:39 otherwise it’s pretty dangerous so what
49:41 you can see here is the amount of sway
49:43 that occurred day two to Day N first of
49:45 all really wasn’t very different and you
49:47 can see was very different in The Zed
49:48 drug versus the lber xent scary lber
49:52 xent didn’t impair driv impair driving
49:54 performance and no drivers had to stop
49:57 but three people in the Z in the zone
50:01 drugs this is a different Z drug them
50:03 before had to actually pull over because
50:06 they felt drowsy they didn’t feel safe
50:07 to drive so if you’re using that for
50:09 Sleep chronically that’s a little scary
50:11 that you’re driving now dreams remember
50:14 Leber said well I’ll show you actually
50:16 improve stages three and REM sleep stage
50:18 three is healing REM is dreaming so
50:21 suddenly you’re going to start dreaming
50:22 if you haven’t dreamed for years and
50:23 years and years and you suddenly dream
50:25 can be fantastic for many people but for
50:27 some people it can be a bad dream that’s
50:29 scary so I warn you if you’re going to
50:31 use an rexan antagonist is the name
50:34 of it um that you may have more dreaming
50:37 and you could have a bad dream and that
50:39 can be quite scary and what I do with
50:41 that it depends on how bad that dream is
50:43 sometimes I tell them to take a little
50:44 break for a few days but in virtually
50:46 all my patients they’ve had a bad dream
50:48 and it’s never recurred as a problem so
50:51 once you sort of have that dream after a
50:52 lot of long time of having dreams it may
50:54 be an issue it’s not very common problem
50:56 that that kind of a bad dream so overall
50:59 for this new drug take it just before
51:01 you go to bed Ure you have seven hours
51:04 until you wake up very important you
51:05 don’t take it if you’re going to be up
51:06 in four hours you have to catch an early
51:08 flight you’ll miss your flight don’t mix
51:10 it with anything else don’t mix it with
51:12 alcohol don’t mix it with over the
51:13 counter sleeping age you’re less likely
51:15 to have next morning effects but some
51:17 sedation is still possible it usually
51:19 gets better with time and you’ve got to
51:21 give it at least a couple week trial at
51:23 the 5 milligram before you can increase
51:25 the max maim dose of 10 so that’s the
51:27 dosing of Canada up to 10 milligrams 7
51:31 hours before you plan to wake up in the
51:33 morning if you’re already taking a sleep
51:36 medication especially a zed drug you
51:38 can’t just stop a sedating medication
51:41 and start the dgo because you’re going
51:42 to have withdrawal of the other
51:44 medication so again if you’re on those
51:47 you can advise your doctor there a
51:48 website called switch RX where you can
51:50 put the different medications you’re on
51:52 here I put zop and lorx sand and tells
51:54 you what to do
51:56 to cross taper your drugs over the
51:57 course of the next few weeks and that
52:00 way you’re slowly reducing one and
52:02 getting rid of the withdrawal that
52:03 occurs while you increase the lumber
52:04 accent as you have to there’s an example
52:06 for a zed drug here’s trazodone the
52:09 tricyclic very common to use it again
52:11 waiting down one as you increase the
52:13 other all right so switch RX is the name
52:15 of that site so sleep cycles very
52:18 important right what do the drugs do so
52:20 if you can see here many of them are
52:22 decreasing REM sleep many of them May
52:25 decrease also the stage three sleep the
52:28 Rex antagonist from the work that’s
52:29 being done show it’s either keeps stable
52:31 or increases the stage three sleep but
52:34 definitely increases the REM sleep so
52:36 again if you think about it from what
52:37 sleep is supposed to do for your brain
52:39 turn it off and allow you to re to
52:41 recharge uh this is the drug for you so
52:45 I summarize sleep and insomnia have a
52:47 bidirectional relationship both are
52:49 going to significantly affect quality of
52:51 life preventing migraine leads to better
52:53 sleep and sleep Improvement reduces the
52:56 frequ severity and frequency of migraine
52:59 some prophylactic medications will also
53:00 help you sleep look out for those other
53:03 conditions that can actually you know
53:05 present as insomnia and lead to tired
53:07 especially sleep apnea this newest CL
53:10 class of drugs has some theoretical
53:12 Improvement in pain and headache based
53:14 on those models I’ve showed you and I
53:16 hope this has helped you more
53:17 importantly not put any of you to