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Britt Talley Daniel MD
7777 Forest Lane
Dallas, Texas 75230
Tips for Sleeping Well
Items 1 through 4 are called normal sleep hygiene and should be done by everyone.
1. Establish a daily sleep/wake schedule. This means keeping a consistent time each day for waking up the morning and going to bed each night. Try to stay within 30-60 minutes of these times every day. This includes through the weekend, holidays, and vacations. In general allow AT LEAST 7 -8 hours of sleep each night. As we age, we need less sleep, so someone in his eighties may need only 6 1/2 hours, while teenagers may well need 9-10 hours.
2. Be careful with naps. It’s okay in general to take a short nap after lunch, a siesta, but avoid a long nap. If you can’t do this on your own, then set an alarm for a brief 15-30 minute nap. If you have trouble falling asleep at night when you have napped earlier during the day, then eliminate the nap. Just lie down and rest for 10-15 minutes instead during the day. If you are the type who “never learned to rest” then, LEARN. The relaxing response can be taught at any age.
3. Be careful with caffeine and pseudoephedrine, both of which promote alertness. Caffeine lasts 8 hours. If you go to sleep at night at 11 pm, then don’t drink any caffeine any later than 3 pm. Pseudoephedrine is in a lot of over the counter sinus or cold medicines-such as Sudafed, Claritin D, or Tylenol Sinus.
4. Regular physical exercise promotes sleeping well. The American Heart Association recommends that every body exercise aerobically for 20 minutes 3 times a week to decrease the risk of atherosclerosis. As a physician I rarely see patients who do manual labor-carpenters, maids-who have trouble sleeping. Exercise promotes the relaxing response. A warning here is that some persons get too jived up after exercise to go to sleep. They should exercise earlier during the day. Exercise also induces endorphins, brain neurochemicals that reduce pain and promote calming.
5. A low volume of a high calorie carbohydrate just before bedtime promotes sleep. I’m talking about something like the proverbial “warm glass of milk.” This has been studied scientifically and shown to work. You have to be careful here with the calories and cholesterol.
6. It’s okay to get out of bed and go to another room for awhile, if you can’t fall asleep when you first try. Then you may read , preferably something not too interesting , technical, or work related, for 10-15 minutes. However, watching TV or doing housework are not good options. They’re too stimulating.
7. Home remedies, vitamins, food supplements, and over the counter sleeping pills don’t usually work for long term sleeping problems. Therefore avoid them. This includes Benadryl which is in Tylenol PM, other antihistamines, and Chloral Hydrate. Melatonin is a drug that may rarely work for small subset of patients with insomnia. Unfortunately, it doesn’t work for everyone. A dose of 3-12 mg of melatonin may be tried.
8. Ambien is a class 4 narcotic, hypnotic sleeping pill with abuse potential that has been approved for chronic use. Some patients are drowsy after using it and may be up at night and perform automatic funtctions, like raiding the refrigerator. Other hypnotics are Restoril and Dalmane. Rozerem is a non narcotic drug that works on the melatonin brain stem system.
9. Alcohol and minor tranquilizers (the Benzodiazepine drugs-Valium, Xanax, Ativan)-don’t work that well either because they don’t last all night and are not good long term options.
10. The majority of patients who have chronic sleeping problems also have psychological reactions or conditions that interfere with sleep. Work directed toward resolving conflicts (psychotherapy, cognitive behavioral therapy) may be helpful. Sleep lab information states that half of patients in America with insomnia are anxious and a quarter of them are depressed. These are the most common causes of trouble sleeping.
11. The older antidepressant medications are, in general, safe for chronic sleep disorders. Examples here would be: Elavil (amitriptyline), Desyrel (trazodone), Tofranil, or Pamelor. All of these drugs have a sedating quality which will allow normal physiological sleep. They are not addictive or habituating. They commonly have mild side effects of a dry mouth which improves with therapy. These are the drugs that may be used for long term sleep disorders. Trazodone comes as a 50 mg tablet and this works well for the majority of patients with trouble sleeping. However, if this dose is too high the patient should break it in half and take 25 mg. A maximum of 150 mg/night may be used. If the patient doesn’t sleep all night on 50 mg then he should increase the dose by 25 mg /night per week until he sleeps all night. The same approach may be used with amitriptyline where the dose may be started at 10 mg and can be just adjusted upward by 10 mg/night to about 50 mg until the patient sleeps all night.
12. Sleeping is an important issue with migraine because too much or too little sleep may make it worse. These sleep tips will help treat migraine in a sense.
Britt Talley Daniel M.D.
7777 Forest Lane Suite B-220
Dallas, Texas 75230
Medication Overuse Headache
The International Classification of Headache II describes medication overuse headache (MOH) as a syndrome related to overtreating. Chronic Daily Headache is a term that implies having headache over 15 days a month. A significant number of these patients have MOH which is now 80-90% of new patients seen in specialty headache clinics and affects 4 million people yearly. MOH may come from overtreating with simple pain killers like caffeine, Tylenol or Advil, opioid narcotics, pain killers with barbiturates, or triptans. Patients typically rotate to different drugs and take many drugs at the same time that may cause MOH. After awhile the preexisting headache problem, which is usually migraine, but may also be tension type headache, becomes transformed from an intermittent to a chronic headache problem. It is like what happens to the patient who drinks a lot of coffee every day and then gets a headache when they don’t. When the brain becomes sensitized to these drugs repeat dosing causes neuro-inflammatory chemicals to be released in the brain which keeps the headache going. The patient develops a constant, daily headache problem often times with sensitivity to light, nausea, and irritability. Because serotonin levels in the brain drop, the patient may also develop anxiety, depression, poor concentration, and insomnia, which also are core symptoms.
Drugs that can cause this syndrome are:
Caffeine, such as Excedrin, BC Powder, Vanquish; pseudoephedrine (Sudafed) the decongestant in over the counter sinus meds, such as Tylenol sinus or Advil sinus, or the D in Allegra-D; Ergotamine drugs—Cafergot, Wigraine; Triptans—Imitrex, Maxalt, Zomig, Axert, Frova, Relpax, or Amerge; NSAIDS—(Nonsteroidal Anti-inflammatory Drugs) such as Motrin (ibuprofen, Advil), Naprosyn/Anaprox (Alleve), and Tylenol; Narcotics—Vicodin (hydrocodone, Narco), Demerol, MS OxyContin, Darvocet, Darvon, Tylenol with codeine; Drugs with barbiturates– Fiorinal, Fioricet, Phrenilin, Esgic.
The International Headache Society criteria for medication overuse headache are:
Triptans or Ergotamine intake >10 days/month
Non-opioid simple analgesics >15days/month
Opioids or Analgesics combined with barbiturates >10days/month
The only effective treatment for medication overuse headache is stopping the offending drugs, usually on 1 day, or sometimes by tapering over several weeks if the patient has been on a high dose of an opioid or barbiturate for a long time. Unless the patient was treated with “Bridge Medication” a terrific headache would come after stopping medication and then the headache would clear. The patient has to stay off any drug on the list above during this time. Bridge medication is: one or two weeks dose of oral cortisone, usually as Medrol Dosepak, for the chemical brain inflammation and Migranol nasal spray every 3 hours as needed for acute treatment of headache. The time for clearing of MOH varies from several weeks to 1-2 months, depending on the type, amount, and duration of medication abuse. Clearing may be noted by 5 headache free days after which regular acute migraine Rx may resume. The patient should limit painkillers to no more than 2 days/ week for the rest of their life. Preventive medications such as topiramate, amitriptyline, or beta-blockers may started, hopefully to reduce the number of monthly migraines. 40% of patients with MOH have generalized anxiety disorder (GAD) and 50% have depression which may need treatment. 50% of patients with MOH get it again.
Caffeine is a Drug
The current 1994 edition of the Diagnostic and Statistical Manual for Psychiatric Diagnosis (DSM IV) added a new drug to the list of known addictive drugs—Caffeine, in amounts as small as 120 mg/day. Criteria for caffeine withdrawal: Prolonged daily use of caffeine, abrupt cessation or reduction of total caffeine use, closely followed by headache and one or more of the following symptoms — fatigue/drowsiness, anxiety/depression, nausea/vomiting–, clinically significant distress or impairment in social, occupational or other important areas of functioning.
The diagnostic criteria for caffeine intoxication are recent consumption of caffeine, use in excess of 250 mg a day and the development of five or more the following signs during, or shortly after caffeine use: Restlessness, nervousness, excitement, insomnia, flushed face, diuresis, gastrointestinal disturbance, muscle twitching, rambling flow of thought and speech, tachycardia or cardiac arrhythmia, periods of inexhaustibility, or psychomotor agitation.
Approximate amounts of caffeine in various beverages:
Coffee, grande 16 oz Starbucks 550
Coffee, tall 12 oz Starbucks 375
Coffee, short 8 oz Starbucks 250
Redline RTD 250
NoDoz, max strength or Vivarin 200
7-Eleven Big Gulp cola 64 oz 190
Coffee non-gourmet 8 oz 135
Coffee instant 8 oz 95
Cola 12 oz 35
Mt. Dew 55
Dr. Pepper 39
Cappuccino, 8 or 12 oz 35
Expresso Starbucks 1 oz 35
Tea, green or instant 8 oz 30
Chocolate dark, semisweet 1 oz 20
Coffee decaf Starbucks 8 or 12 oz 10
Coffee decaf non-gourmet 8 oz 5
Hot chocolate or cocoa 8 oz 5
Chocolate milk 1 oz 5
Liquid Speed (amount concealed within a proprietary formula)
Caffeinated water ?
Pharmacologically, caffeine acts as a central nervous system stimulator, a point that is well made by the coffee ad on TV which calls it “the think drink.” The duration of the effect of the drug is 6-8 hours, but even one drink in the morning will interrupt sleep in some persons. Caffeine also acts as a constrictor of smooth muscle, which is found in arteries, the bladder, and the colon. It is the arterial vasoconstrictive action which helps with mild migraine (Excedrin, B.C. Powder, and Vivacin) and may lead to the rebound vasodilatation headache when one withdraws from caffeine. The smooth muscle effect also acts as a mild stimulant on the bladder, promoting urination and in the colon, a bowel movement.
I urge all Caffeine addicted patients, migraine patients, Panic Disorder patients, and patients with sleep disorders to taper off caffeine (which, as I said above, is a drug).
Consider what the migraine expert, Dr. Marcelo Bigal, wrote in October 2009: ”The role of caffeine in the evolution from episodic into chronic headaches is of enormous interest, due to wide populational exposure to caffeine. In the population, individuals with chronic migraine are more likely to be high caffeine consumers while they had episodic headaches, as compared to individuals that did not develop chronic migraine. Abrupt withdrawal of caffeine in individuals with chronic migraine is associated with rebound headaches, further supporting the importance of this substance as a risk factor.” http://www.discoverymedicine.com/Marcelo-Bigal/2009/10/12/migraine-chronification-concept-and-risk-factors/