Prevalence of Headache and its Association
With Sleep Disorders in Children
Ugur Isik, MD*, Refika Hamutcu Ersu, MD†, Pinar Ay, MD‡, Dilsad Save, MD‡,
Ayse Rodopman Arman, MD§, Fazilet Karakoc, MD†, and Elif Dagli, MD†
An association between headache and sleep distur-
bances has been reported in previous studies, but there
is a lack of research examining this relationship in a
community sample of children in order to reveal the
magnitude of the problem. Among 32 District Educa-
tional Directorates in Istanbul, nine school districts
and within each district eight schools were randomly
selected. A questionnaire consisting of sociodemo-
graphic variables and evaluating headache and sleep
disturbances was sent to students’ homes to be com-
pleted by their parents. The prevalence of headache
was 31.4% (95% confidence interval: 29.5-33.4%).
Migraine prevalence was 3.3%, whereas nonmigraine
headache prevalence was 28.1%. The prevalence of
headache was similar between males and females
(29.6% vs 33.3%, P > 0.05). The frequency of head-
ache increased with age for both sexes. Snoring, para-
somnias, sweating during sleep, and daytime sleepiness
were more common among children with migraine
compared with nonmigraine and no headache groups.
Headaches are common among schoolchildren. Be-
cause children with migraine headaches have a high
prevalence of sleep disturbances, they should always be
evaluated for the presence of sleep problems.
by Elsevier Inc. All rights reserved.
E. Prevalence of headache and its association with sleep
disorders in children. Pediatr Neurol 2007;36:146-151.
Both headache and sleep disorders are common prob-
lems in children [1,2]. Although it is common thinking
that headache and sleep problems are related, there has
been little research in this area. A few studies examined
this relationship in children and found a high frequency
of sleep disturbances involving sleep quality, night
awakening, nocturnal symptoms, and daytime sleepi-
ness in children with headache [3,4]. However, those
studies were performed in children from pediatric
neurology and headache clinics so they represented a
select group. To our knowledge, this is the first popu-
lation-based study which examines this particular rela-
tionship in children.
The aim of the present study was (1) to determine
headache (migraine and nonmigraine headache) preva-
lence among school-aged children, and (2) to determine
the association between headache and sleep disturbances
among these children.
This study was part of the Sleep Disordered Breathing
in School Children Project , and it was approved by
the Regional Director of Education, which serves as the
Institute of Human Subject Protection Committee for the
schools in Istanbul. Multistage, randomized sampling was
used for data collection. The city of Istanbul has a
population of approximately 12 million people and there
are 32 school districts. Nine districts out of 32 were
selected randomly. All schools were listed and among
them, 72 were selected by systematic sampling. Classes
were also randomly chosen from every school. The ques-
tionnaire and a personally addressed letter asking for
consent were mailed to the parents. Data collection was
performed between March and May 2002. Among the
2746 students, 2228 returned fully completed question-
From *Division of Pediatric Neurology, Acibadem Institute of
Neurological Sciences, Istanbul, Turkey;†Department of Pediatrics,
Division of Pediatric Pulmonology, Marmara University School of
Medicine, Istanbul, Turkey;‡Department of Public Health, Marmara
University School of Medicine, Istanbul, Turkey; and§Department of
Child Psychiatry, Marmara University School of Medicine, Istanbul,
Communications should be addressed to:
Dr. Isik; Dr. Kazim Lakay S. No. 9/37; Ciftehavuzlar;
34726 Istanbul, Turkey.
Received July 5, 2006; accepted November 22, 2006.
146PEDIATRIC NEUROLOGYVol. 36 No. 3© 2007 by Elsevier Inc. All rights reserved.
doi:10.1016/j.pediatrneurol.2006.11.006●0887-8994/07/$—see front matter
The questions about the demographic data included the
name, date of birth, sex, home address, home phone
number, school name, and class name of the student. The
55-item questionnaire consisted of two parts: questions
related to headache and sleep disorders. The questions
about headache consisted of time of onset; frequency
(every day, more than once a week, once a week, once a
month, other); duration—minutes (less than 1 hour), hours
(1 hour or more), and days; severity (mild, moderate,
severe); limitation in daily activities; aggravating factors
(exercise, stress, tiredness); unilateral headache; associ-
ated symptoms (nausea, vomiting, photophobia, and pho-
nophobia); medication history; and family history. Head-
ache was classified according to the International
Headache Society (IHS) 2004 criteria . Headache last-
ing hours (1 hour or more) was considered as migraine.
We did not specify headache lasting between 1-2 hours
and headache lasting more than 2 hours each, as we
thought getting headache duration details, more than 1
hour long, would be difficult to obtain through a ques-
tionnaire. At least two or more of the following criteria
had to be present for migraine diagnosis: unilateral
location, pulsating quality, moderate to severe in inten-
sity, and aggravation by physical activity. In addition,
during the headache either (1) nausea and/or vomiting,
or (2) photophobia and phonophobia had to be present.
Headache was categorized as moderate to severe if the
headache was limiting daily activities or if parents or
child rated headache as moderate or severe. The pres-
ence of aura was not questioned in this study, and
therefore a distinction between migraine with or with-
out aura was not made. Headaches not fulfilling these
criteria were considered nonmigraine type headache but
not specified further.
Questions related to sleep disorders included parasom-
nias (bedtime struggle, teeth grinding, sleep vocalizations,
sleepwalking, nightmares), sweating during sleep, exces-
sive daytime sleepiness, and snoring. Parents reported
snoring on a four-point scale: 0 (never), 1 (occasionally),
2 (often), and 3 (always). Habitual snoring was considered
present if parents reported snoring as either often or
always. Excessive daytime sleepiness was considered to
be present if at least one of the following criteria was met:
1—falling asleep during class; 2—falling asleep at theater/
concert/visiting friends/relatives; 3—falling asleep during
a conversation. The frequency of each parasomnia and
sweating during sleep was evaluated separately (i—every
2-3 months; ii—1-3 times a month; iii—more than 3 times
Figure 1. Headache types according to age groups among males.
Figure 2. Headache types according to age groups among females.
Headache characteristics in migraine and nonmigraine
(n ? 74)
(n ? 626)
once a week
Once a week
Once a month
Few a year
less than 1 hour
1 hour or more
Limitation in activities*
Nausea and/or vomiting
* Limitation in physical activities while the child is experiencing
147Isik et al: Headache and Sleep Disorders
a month; iv—almost every day); however, it was catego-
rized as present even if it was present occasionally, i.e.
every 2-3 months. All the forms were evaluated by the
same pediatric neurologist for the diagnosis of headache
and its types (U.I.).
Statistical analyses were performed using SPSS for
Windows Release 11.0. Pearson chi-square test and the
chi-square for trend analysis were used for the comparison
of categorical variables. The strength of association was
described by odds ratios and 95% confidence intervals.
Sleep characteristics were analyzed among children with
and without headache after adjusting for age and sex. P ?
0.05 was accepted as the level of statistical significance.
Seventy-two schools from nine school districts were
surveyed. Of the 2746 children participating in the study,
2395 (87.2%) returned the questionnaire and among them
2228 (81.1%) were fully completed. Females and males
were almost equally represented in the study (49.1% and
50.9%, respectively). The age of the students ranged from
6 to 13 years with a mean and a standard deviation of 8.4
? 1.4 years.
The prevalence of headache was 31.4% (95% confi-
dence interval [CI]: 29.5-33.4%). Among the 2228 partic-
ipants, 74 (3.3%) fulfilled the migraine criteria, whereas
626 (28.1%) had nonmigraine headache. The rate of
headache was 33.3% among females and 29.6% among
males; the difference was not statistically significant. The
rate of headache increased with age for both sexes. Among
females the rates for ?7 and ?10 years of age were 27.0%
and 40.6%, respectively (P ? 0.001, chi square for trend).
For males the corresponding rates were 23.8% and 34%,
respectively (P ? 0.017, chi-square for trend).
The prevalence of migraine was similar for both sexes,
3.0% for the females and 3.6% for the males. There was a
slight increase in the rate of migraine with age; among
females the rate was 2.2% for 7-year-olds and 3.8% for
10-year-olds, among males it was 2.4% for 7-year-olds
and 4.5% for 10-year-olds. Yet the difference was not
statistically significant. Headache type according to age
groups by sex is presented in Figures 1 and 2.
The rate of family history of headache among migraine
and nonmigraine headache groups were 87.3% and 65.6%,
respectively (P ? 0.001). 77.5% of students experiencing
migraine and 63.8% with nonmigraine headache were
using pain relief medications (P ? 0.02). Table 1 summa-
rizes the characteristics of headache among migraine and
Association of Headache With Sleep Disorders
The rates of all sleep disturbances were significantly
higher among the migraine group, with a trend towards
a lower frequency among nonmigraine and nonhead-
ache groups. Table 2 presents the odds ratios of head-
ache types for the presence of several sleep character-
istics while controlling for age and sex. The odds ratio
of habitual snoring for the nonmigraine headache group
was 1.39, whereas it was 1.97 for the migraine group.
The odds ratios of daytime sleepiness for the nonmi-
graine and migraine group were 1.78 and 2.17, respec-
tively. When snoring was controlled, odds ratios of
daytime sleepiness for nonmigraine and migraine head-
aches were 1.68 (95% CI: 1.33-2.12) and 2.00 (95% CI:
As medications can have adverse consequences on
sleep, headache patients taking any medications were
compared with headache patients taking no medications.
There was no statistically significant difference in the
frequency of sleep disturbances among headache sufferers
who used medications vs those who did not use any
medications (P ? 0.05).
Table 2.Sleep characteristics in children with and without headache*
Presence and Type of
Headache SnoringBedtime Struggle Teeth Grinding
OR (95% CI)†
OR (95% CI)†
1.39 (1.14-1.68)1.94 (1.59-2.37)1.78 (1.43-2.22)1.87 (1.53-2.29)
P ? 0.001
P ? 0.001
P ? 0.001
3.58 (2.17-5.88)1.97 (1.23-3.16)
P ? 0.001
P ? 0.001
P ? 0.001
* P values are adjusted for age and sex.
†Odds ratios are calculated using the nonheadache group as the reference category.
CI ? Confidence interval
OR ? Odds ratio
148PEDIATRIC NEUROLOGYVol. 36 No. 3
There are a few reports which reveal an association
between headache and sleep disorders in children; how-
ever, these studies were performed on a limited number of
children within selected populations [3,4,7]. This report is
the first population-based study among children that ex-
amines this relationship.
The association between headache and sleep disorders
can have different aspects. One may cause the other, or
they may share a common intrinsic etiology. Both head-
ache and sleep disorders have been thought to be caused
by neurotransmitter changes or circadian rhythm disorders
. Serotonin secreted from dorsal raphe nucleus is
associated with migraine and sleep cycle [9,10]. It has
been demonstrated that the suprachiasmatic nucleus of the
hypothalamus regulates the release of serotonin from
dorsal raphe. Serotonin decreases rapid eye movement
sleep, and its decline in systemic circulation has been
associated with migraine .
The prevalence of migraine ranges from 3.0% to 10.6%
according to different studies [12-18]. Migraine preva-
lence was 3.3% in the present study, which is comparable
but lower than most of the previous studies. It should
be noted that the diagnostic criteria used as well as the age
group studied might result in different rates for headache
types. Two recent studies reported the prevalence of
pediatric migraine in the Middle East. The first one
performed in Iran, which evaluated a random sample of
1868 teenaged females (aged 11-18 years) reported an
overall prevalence rate of 6.1% for migraine . The
second study evaluated 1400 randomly selected Saudi
children in grades 1 through 9. Overall headache preva-
lence was 49.8%, and the prevalence of migraine was
7.1% . A meta-analysis of prevalence studies suggests
that migraine is most common in North and South Amer-
ica, followed by Europe, and lowest in Africa and Asia
. A recent population-based study performed in
schoolchildren in Turkey aged 8-16 years revealed a
current headache prevalence of 31.3%, which was similar
to our findings. Yet in the mentioned study, the reported
migraine prevalence was 10.4% . The reason for the
differences between the prevalence rates of migraine could
be explained by the criteria used for the diagnosis of
migraine. The previous study used the revised IHS criteria
for the diagnosis which had an increased sensitivity for the
diagnostic rate of migraine . The variations between
the two studies could also have resulted from the age
difference in the survey (younger in our study) as well as
the difference between the two geographic locations.
Istanbul is located in northwestern Turkey and Mersin is in
Migraine prevalence increases with age. The present
study determined an increasing trend in the headache
prevalence as children got older. There was a statistically
significant difference between the ?7-year-olds and ?10-
year-olds among both sexes, but this difference did not
reach statistical significance for migraine. According to
Stewart et al. , the incidence of migraine without aura
in females peaked between the ages of 14 and 17 years. In
schoolchildren, the prevalence of migraine increases with
age, with male preponderance in children aged less than 12
years and female preponderance thereafter . In the
present study, migraine prevalence was slightly higher in
males compared with females. However, the age range
was between 6 and 13 and only partially included the
adolescence period. So we may not have observed the
usual peak of migraine observed in adolescent females.
The rate of family history of headache was 87.3% in this
study, which is consistent with previous studies disclosing
a similar headache frequency among family members
Association of Headache With Sleep Disorders
All of the sleep problems we studied among school-
aged children were more frequent among migraine suffer-
ers compared with nonmigraine and no headache groups.
Table 2.Sleep characteristics in children with and without headache*
Sleep WalkingNightmares Sweating During Sleep Excessive Daytime Sleepiness
1.28 (0.80-2.06) 1.93 (1.55-2.41)2.20 (1.81-2.66)1.78 (1.41-2.25)
P ? 0.05
P ? 0.001
P ? 0.001
P ? 0.001
P ? 0.001
P ? 0.0010.004
149Isik et al: Headache and Sleep Disorders
There was a trend between the three groups; the preva-
lence of all the sleep disorders was the highest among the
The first sleep disorder studied was snoring. The odds
ratio of habitual snoring for the nonmigraine headache
group was 1.39, whereas it was 1.97 for the migraine
group. According to Miller et al.  the rate of snoring
among children with migraine is 23%. Torok et al. 
studied snoring in 11- to 15-year-old schoolchildren and
found that headache was more common in children who
snored frequently. Bruni et al.  found a 2.9% rate of
snoring in children with migraine headache. There is a
well-known association between cluster headaches and
obstructive sleep apnea as well [26,27]. Hypoxemia during
rapid eye movement sleep is thought to result in cluster
headache. Snoring can be responsible for an increased rate
of headache with a similar mechanism.
Migraine headaches were also associated with parasom-
nias. Bedtime struggle, teeth grinding, sleep vocalizations,
nightmares, and sleep walking rates were highest among
the migraine group, followed by the nonmigraine and no
headache groups (Table 2). Our results are concordant
with previous studies which revealed a high correlation
between parasomnias and migraines. Bruni et al.  found
that the rate of night sweating, sleep talking, bruxism, and
nightmares was higher among migraine patients compared
with tension headaches and control groups. However,
sleepwalking, bedwetting, and sleep terrors were not
higher in the migraine group. Barabas et al.  found a
high frequency of somnambulism in children suffering
from migraine. In the present study, sleepwalking had a
borderline statistical significance, although all other
parasomnias were highly associated with migraine
headaches. The frequency of parasomnias in the general
population is lower compared with children with neu-
rologic problems .
Headache was also associated with excessive daytime
sleepiness. Increased sleepiness was determined to be
associated with headaches in previous studies performed
in children [3,4,7]. Although it is difficult to evaluate
whether it is the cause or the result of headache, it is more
likely to be the consequence of sleep disorders. Excessive
sleepiness can be found in children with sleep-disordered
breathing . In the present study, when snoring was
controlled, headache type still continued to increase day-
One of the drawbacks of this study is that it is based on
parental reports. Because the data were collected via
questionnaires, history taking and physical examination
are lacking. However, parental information has proved to
be an effective method for diagnosing sleep disorders .
Sasmaz et al.  reported that 74% of parents are aware
of their children’s headache, and migraine type of head-
ache is one of the factors that affect the awareness level of
parents. It is also known that physical and neurologic
examinations rarely affect migraine diagnoses in the gen-
eral population . This study is the first population-
based study which examines the particular association
between headache and sleep problems in a large sample.
Another possible limitation is the question of headache
duration. The headache duration was not specified more
than hours in the questionnaire, so headaches lasting
between 1-2 hours were considered as migraine, theoreti-
cally. IHS criteria suggest that migraine can last 1 hour in
children, although headache lasting less than 2 hours
requires prospective diary studies .
Although an association between headache and sleep
disorders was demonstrated in this cross-sectional study, a
causal relationship cannot be determined without a follow-up
study looking at the treatment effect.
Bruni et al.  demonstrated a reduction in the
frequency and duration of migraine in the group of
children who received sleep hygiene education compared
with those who received no education. The findings
reported herein also suggest that physicians taking care of
children with headache should ask questions about sleep
behaviors as part of the standard headache assessment.
Such evaluations are important because children may not
raise concerns about sleep-related problems.
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