Migraine and sleep: why too little and too much sleep work the same way

“All week I sleep five hours a night and nothing happens. Then on Sunday I finally sleep in until ten — and wake up with a migraine.”

When someone tells me this, I almost always hear a note of indignation in their voice. And I understand it. Sleep is supposed to be medicine, the thing you have earned after a hard week. It seems unfair that it could also be a trigger. And yet people with migraine describe it often: an attack comes after a night when they slept too little, and just as much after a night when they slept far longer than usual.

In this article I would like to explain why this happens, what we know about the link between sleep and migraine and what we don’t yet know, and how you can arrange your sleep so that it supports a migraine brain — without sleep becoming a new obsession.

In short: migraine is a brain disorder

As in every article about migraine, I need to say this first: migraine is not a psychosomatic symptom. It is a neurological disease in which the brain is more sensitive to changes in the body and the environment. Sleep doesn’t cause migraine. But — like stress, hormonal changes or a skipped meal — in a brain that is already sensitive it can contribute to an attack being triggered.

The diagnosis is made by your GP or a neurologist, who is also the only right person to ask about medication. You won’t find it in this article. I will write about the part that is closer to my own work: the habits, thoughts and relationships around sleep. I wrote about why an attack often comes only once the pressure eases in Stress and migraine: why the attack often comes only after the pressure. Sleep is often the hidden link in that story.

How closely they are connected

When you ask people with migraine about their triggers, disturbed sleep is among the most common answers. In Leslie Kelman’s large clinical study, about half of the people asked named it as a trigger, which puts it just behind stress, hormonal changes, skipped meals and the weather.

But the link doesn’t run in only one direction. People with migraine more often report insomnia, unrefreshing sleep and waking up with a headache. An attack at night or early in the morning can interrupt sleep, and poor sleep can lower the threshold for a new attack the next day. Researchers who study this link point out that it is probably a matter of shared mechanisms in the brain, not simply one thing “causing” the other.

In people who have attacks very often, sleep problems are even more pronounced. Whether poor sleep contributes to migraine becoming more frequent, or the other way round, research hasn’t yet settled. Probably both are true.

Why too little and too much work the same way

At first glance it seems illogical that two opposite things — too little and too much sleep — should have the same effect. It becomes easier to understand when you consider what many migraine triggers have in common: change.

The brains of people with migraine are particularly sensitive to departures from their usual rhythm. A key role here is probably played by the hypothalamus, a small part of the brain that regulates, among other things, sleep and wakefulness, hunger, body temperature and hormones. According to imaging studies, the same area is already active in the premonitory phase, hours before the pain — the time when yawning, tiredness and food cravings appear. The hypothalamus is also the centre of the circadian rhythm, the internal clock that makes sure the body prepares for sleep and for wakefulness at roughly the same time every day.

When you sleep two hours less, this rhythm is shifted. When you sleep two hours more, it is shifted in the other direction. For a brain that dislikes change, both nights are a departure. This isn’t a definitive explanation — science doesn’t have one yet — but it is an explanation that fits most of what people describe.

The Sunday migraine: sleep never comes alone

With oversleeping, we need to be honest about one more thing. When you sleep until ten on Sunday, it isn’t only your sleep that shifts. The whole morning shifts. The first coffee, which on weekdays you drink at seven, comes at half past ten. Breakfast, which you normally eat at half past seven, comes at noon. A body used to caffeine at a certain time can respond to the delay with a headache, and a skipped or delayed meal is itself one of the common triggers.

Researchers pointed out decades ago that weekend attacks may be linked to precisely this — a combination of longer sleep, later caffeine and a different rhythm of meals. The “weekend migraine” is therefore a good example of how hard it is to pick out a single factor from the whole. It isn’t necessarily sleep itself that is to blame. Perhaps it is the change to the whole morning.

For everyday life, this is actually good news. It means you don’t have to get up at six at the weekend to avoid an attack. But you can try to make the difference between a working day and a day off smaller — and to keep coffee and breakfast roughly where they belong.

Not just how much, but how

When we talk about sleep, we usually talk about hours: seven, eight, six. But one of the more recent studies suggests that the quality of sleep matters too. In 2020, Suzanne Bertisch and colleagues followed the sleep of adults with episodic migraine for several weeks, using a wrist-worn device and a diary. A short night on its own did not predict an attack the following day. But they did find a link with fragmented sleep, with many awakenings and little of the time in bed actually spent asleep — and with some delay, not already the next morning.

This fits what many people describe: one short night isn’t necessarily dangerous; it becomes riskier when sleep is broken up several nights in a row. And fragmented sleep is often linked to stress, worries and tension a person can’t put down. I have described how this happens in the body, and why so many people wake up right in the middle of the night, in Waking at three: what cortisol and a racing mind are telling you.

If you have been sleeping badly for a long time, you may also find the short explanation of insomnia in the knowledge base helpful — when it is a passing bad patch and when it is something that needs its own treatment.

Sleep as remedy and as trap

Many people with migraine say that during an attack, sleep helps them most. A darkened room, silence, a few hours of sleep — and when they wake up, the worst is over. This is no coincidence: sleep is one of the ways an attack resolves for many people, especially children.

But a trap can hide right here. Someone who has frequent attacks can start using sleep as a refuge: an afternoon nap at every hint of a headache, lying in for a long time in the morning when they don’t feel well, going to bed early to “sleep off” the discomfort. Each of these is understandable. Together, though, they can loosen the sleep rhythm so much that it becomes harder to fall asleep in the evening and sleep breaks up at night — and this opens the way for new attacks.

There is no simple solution here. If sleep helps during an attack, there is no need to forbid it. But it makes sense to distinguish between the sleep an attack needs and the sleep you use to avoid the day. With the latter, the question of what exactly you are avoiding also deserves some attention.

When insomnia joins migraine

For some people, migraine is joined by genuine chronic insomnia. Then it is no longer just about the odd bad night, but about a pattern: the person lies awake, worries about how they will sleep, and because they know poor sleep can trigger an attack, they worry all the more. A double fear forms — of insomnia, and of the migraine that might follow.

We know this mechanism well from insomnia itself. I have described how worrying about sleep becomes the reason you don’t sleep in Fear of insomnia, and why chronic insomnia is often not a sleep problem but one of a constantly aroused nervous system in Hyperarousal: why chronic insomnia is not a sleep problem but an arousal problem. With migraine this arousal can be even greater, because the person has good reason to be alert to every signal from the body.

The good news is that there is a method for insomnia with very strong evidence: cognitive behavioural therapy for insomnia (CBT-I). And early research suggests it helps people with migraine too. In a small pilot study by Todd Smitherman and colleagues, headache frequency in people with migraine and insomnia fell more after CBT-I than in a comparison group. Earlier still, Anne Calhoun and Shirley Ford tested simple behavioural sleep instructions in women with chronic migraine — a regular bedtime, no television in bed, no daytime naps. In several women in the group given the instructions, chronic migraine reverted to episodic migraine. Both studies are small and need to be confirmed, but they point in a direction.

Sleeping as a couple: when the rhythm isn’t only yours

Sleep rarely belongs to one person alone. You share it with a partner, with children who wake up, with a family that has its own rhythm. As a therapist in training in relational family therapy, I often notice that couples rarely really talk about sleep — until it becomes a source of tension. With migraine, that can happen quickly. A conversation might go something like this (a composite, not a real person):

“I don’t understand why you have to get up at eight on a Saturday. It’s the only day we can have a lie-in.”
“Because every time I sleep until ten, I get a migraine in the afternoon. And then there’s no Saturday for me or for you.”
“But I need to catch up on sleep.”
“You can. Just don’t ask me to stay in bed with you.”

Both are right in this conversation. One needs rest, the other needs steadiness. The problem arises when one person’s need starts to be experienced as rejection by the other — “you don’t want to be with me” against “you don’t understand my illness”. It helps if the couple agree on a solution that isn’t shared at all costs: one gets up and makes coffee at the usual time, the other sleeps longer, and then they have breakfast together. Small agreements like these often change more than even the best advice about sleep hygiene.

Exercise: an anchor for your rhythm

If you notice that your attacks follow irregular sleep, try the one change that has the greatest effect on sleep: settle your wake-up time. Not your bedtime — you can’t order yourself to fall asleep — but the time you get up.

1. Choose a wake-up time you can manage seven days a week. Not the earliest one, but one you can keep on a Sunday too. Let the difference between a working day and a day off be no more than about an hour.
2. Look for light when you get up. Open the window, step out onto the balcony or go for a short walk. Morning light is the strongest signal to your internal clock that the day has begun.
3. Coffee and breakfast stay where they are. If you drink coffee, have it at roughly the same time every day, weekends included. The same goes for your first meal.
4. Keep a simple record for two weeks. Use a sleep diary: when you went to bed, when you got up, how many times you woke, whether you had a headache the next day. Even better if you combine it with a migraine diary.
5. After two weeks, look rather than judge. Don’t search for proof that you did something wrong. Look for a pattern: are attacks more frequent after a particular kind of night? What of this is in your hands?

The exercise won’t get rid of migraine. But it can spare a brain that dislikes change at least some unnecessary changes.

Where this doesn’t apply

Everything I have written about a regular rhythm has its limits, and it is right that I name them.

Not every morning headache is a migraine. If you often wake up with a headache, snore loudly, your partner tells you that you stop breathing for a moment while asleep, or you are extremely sleepy during the day, tell your doctor. Morning headaches can be a sign of a breathing disorder during sleep, which needs to be examined and treated in its own right — and which no change of habits will fix.

Not everyone has their rhythm in their own hands. Shift work, young children, caring for an ill family member — in circumstances like these, the advice “get up at the same time every day” can feel almost insulting. Then it makes sense to look for a smaller anchor that is still possible: the same time for your first coffee, a short walk in daylight, the same sequence before bed, whatever the hour.

Rules mustn’t become a new anxiety. If you start measuring every night, experiencing every deviation as a mistake and dreading every Sunday, you have done your sleep more harm than good. No rule is worth sleep turning into an exam. I wrote about why sleep hygiene on its own often isn’t enough in What sleep hygiene is — and why on its own it often isn’t enough.

Sleep isn’t to blame for every attack. Even with the most orderly sleep, attacks will come. That isn’t a sign you haven’t tried hard enough. Migraine is an illness, not a test of discipline. If attacks are frequent or are changing, the right person to see is your GP or a neurologist.

What to remember

• Migraine is a neurological disease. Sleep doesn’t cause it, but it can contribute to an attack being triggered.
• Too little and too much sleep work in a similar way because both are a departure from the rhythm to which a migraine brain is sensitive.
• With a Sunday migraine, it is often the whole morning that shifts — coffee, breakfast, light — not just sleep.
• Quality matters too: fragmented sleep may be more closely linked to attacks than a single short night.
• For migraine with insomnia, CBT-I is a promising help; with loud snoring and morning headaches, see a doctor first.