Circadian factors (worsening after awakening from sleep)

Clinical observations show that migraine attacks have a circadian timing, suggesting a role of chronobiological mechanisms and their alterations in the disease, but little experimental data exists about this issue. Supporting earlier clinical observations of nocturnal migraine (Dexter and Riley, 1975) or early morning migraine (Hsu et al., 1977), a recent study by Gori et al. (2005) documented a preferential timing for occurrence of migraine attacks during the night and early morning hours in a sample of 100 patients suffering from migraine without aura according to the IHS criteria (2004).

The observation of 12 subjects (#23, #42, #138, #147, #159, #162, #189, #230, #382, #405, #515, #555) with a diagnosis of definite persistent aura without infarction, that the intensity of the persisting visual disturbances is worse in the first seconds to minutes after awakening from sleep, may be related to the aforementioned circadian timing of migraine attacks, representing a transitory worsening of the intensity of persistent aura symptoms with an attack of nocturnal migraine without aura (corresponding to item B.9 of the MAS score) or nocturnal migraine with aura (corresponding to item B.10 of the MAS score).

The suggested pathomechanism corresponding to item B.10(b) of the MAS score is confirmed by a report from starrant (subject #138) who recalled a lucid dream displaying a distorted view of his neighbour with "weird visual symptoms" in addition to "concentrated flashing lights", representing the symptoms of a nocturnal attack of migraine aura without headache being incorporated in a dream that culminated in waking up "in the middle of the dream for some reason" (probably the arousal resulting from the ongoing attack of acephalic migraine; see Schönhammer, 2005), after which he "noticed that my VS was a lot worse for about a minute until it went down to a level I am used to seeing".

Sensory deprivation or low blood pressure have been suggested by users of the Yuku forum Visual snow or static as alternative general explanations for the transitory worsening of intensity of persistent aura symptoms after awakening. Whilst it cannot be excluded that these explanations may be applicable to some cases (see box below), both hypotheses are contradicted, as general explanations, by two pieces of clinical evidence. Firstly, there is anecdotal evidence that visual rest may result in an improvement rather than worsening of the intensity of persistent aura symptoms (D.C. Haas, Email to Klaus Podoll, March 23, 2006). Secondly, the intuitive assumption that there is a low blood pressure after awakening is wrong. Blood pressure has a diurnal pattern, falling during the night and rising during the early morning hours prior to awakening.

Definite persistent aura without infarction

"When I wake in the morning the afterimages are always worse and I also see a general corona effect surrounding everything I look at. It is not until I turn on the lights, wake up properly, focus properly and put on my glasses that things settle down."

(Jane10 [subject #23], Email to Klaus Podoll, February 21, 2006)

"This is pretty common for me. Getting up and active gets the morning vs reduced within about 5 minutes."

(viper123456 [subject #42], Yuku forum Visual snow or static - General discussion - Worsening of vs intensity after awakening from sleep, November 18, 2007)

"One more thing...... when I opened my eyes this morning, my visual snow seemed a lot worse for a few seconds, so maybe sleep has an effect on my visual snow?"

(starrant [subject #138], Ezboard forum Visual snow or static – Discussion - All kinds of symptoms! anyone else - age and other stuff, July 8, 2006)

"This morning, I went on a 9 mile run beginning at 06.30 a.m. After finishing the run, I was really tired and fell asleep on my couch for about an hour. Anyway, when I woke up in the middle of the dream for some reason, I noticed that my VS was a lot worse for about a minute until it went down to a level I am used to seeing. I wonder if the REM phase of sleep when you dream has an effect on the VS (making it worse) or if it is just sleep in general that causes it to wosen. Of course, in many of my dreams not surprisingly, I have bad VS in the dream, although sometimes I will dream and not recall any VS. Just wondering what you guys think about this."

(starrant [subject #138], Ezboard forum Visual snow or static – Discussion – Dreams making VS worse, July 22, 2006)

"My dream earlier this morning was fairly standard... I had a dream that I was telling the pastor of my church about the fine cooking of one of the Church members. As the pastor and I walked over to the woman to tell her how great her cooking was, I can remember looking at her and having the view distorted with weird visual symptoms, which I am of course used to in real life. The way I saw her in the dream, however, was not exactly how I see in real life as far as I can remember. There were concentrated flashing lights in my dream visual field as opposed to the floaters and VS. It is really hard to remember exactly how I saw her, but I do remember thinking in the dream about my symptoms and accepting their extreme annoyance without being alarmed. I have also had dreams without VS or at least without thinking about it at all during the dream. I would say though that in perhaps half of my dreams, I imagine my visual symptoms. This makes sense, as dreams seem to be a random combination of your current thoughts and feelings. Also, this may be off topic, but has anyone had dreams where you tell yourself in the middle of the dream that this is a dream? I can remember a few times where I would suddenly stop myself in the dream and think, 'wait... this is just a dream!' I would then remember real life in the dream, and then basically tell myself, 'alright, lets just continue with the dream!' This has happened a few times. Weird huh? Anyway, there are many times where I wake up and don't notice the VS to be any worse. This morning though, it was bad enough that the individual snowy particles looked kind of like giant vibrating bubbles. If I stay in bed, the bad snow will continue, but when I get up, it goes back to 'normal levels' fairly quickly."

(starrant [subject #138], Ezboard forum Visual snow or static – Discussion – Dreams making VS worse, July 22, 2006)

"My vision appears to be temporarly worse ... after waking up in the morning."

(starrant [subject #138], Ezboard forum Visual snow or static – Discussion - Impact of sports?, August 24, 2006)

"It was much worse ... when I opened my eyes in the morning."

"I always wake up with the snow worse... whether I wake up in the middle of the night or sleep all night, it is always worse when I first open my eyes. Does that mean that I had migraine aura all night? Sometimes I have been noticing lately colors swirling or making moving patterns like a kaleidoscope when I wake up, as well as the snow being worse."

(Wendi Triplet Mom [subject #147], Ezboard forum Visual snow or static – Discussion – Waking and night, November 27, 2006)

(Snow1974 [subject #159], Email to Klaus Podoll, August 2, 2006)

"The intensity of visual snow worsens ... in the first minutes after awakening from sleep."

(RT [subject #162], Email to Klaus Podoll, August 18, 2006)

"I ALWAYS have weird visuals upon awakening. They are often slightly different each day and always a repeating pattern usually in black and white though sometimes there can be a blue or yellow thrown in for fun. They always dissipate within a few minutes. While I believe I have had migraine attacks at night, I find it hard to accept that I am having one every night.

My VS is also worse when I first wake up, though with the nifty repeating patterns vying for my attention I don't tend to think much about the VS."

(MisterClean12 [subject #189], Ezboard forum Visual snow or static – Discussion – Another question to ksomething, December 11, 2006)

"[I have] grainy vision or vs... especially... when waking up"

(StormeBrwneyes [subject #230], Ezboard forum Visual snow or static - sleeping pills and vs - Thank you for the welcome... I sure hope this will help, November 17, 2006)

"I know that phenomenon very well: Nearly every morning when I wake up my vision is quite coarse-grained and I am overly sensitive to light. This improves within about a minute after getting up. I have had this for at least ten years, probably even longer."

(Specialist [subject #382], Yuku forum Visual snow or static - General discussion - Worsening of vs intensity after awakening from sleep, November 18, 2007) [more]

"I have the same thing, and I think mine is definitely blood pressure related. For me, it could just be a worsening of vision from the blood pressure (more blurriness, graying out a bit), that makes the VS and such seem worse. The VS and such could also actually be worse. The blood pressure stuff definitely pre-dates the VS/PMA."

(SopuliSusie [subject #405], Yuku forum Visual snow or static - General discussion - Worsening of vs intensity after awakening from sleep, November 18, 2007)

"Also when I wake... in the morning my VS is always significantly worse..."

(jruddy [subject #515], Yuku forum Visual snow or static - General discussion - Experimenting - Ability to change magnitude of VS, February 10, 2008)

"Morgens direkt beim Erwachen ist der visual snow am schlimmsten, wirkt grobkörniger..."

(augenfilm [subject #555], Email an Klaus Podoll, April 15, 2008)

"Morgens ist der Schnee viel gröber, was sich aber nach dem Aufstehen wieder verfeinert und zum üblichen Rauschen zurückbildet."

(augenfilm [subject #555], Forum Augenrauschen - Augenrauschen - Neue Leidensgenossin, May 8, 2008)

References

Dexter JD, Riley TL. Studies in nocturnal migraine. Headache 1975; 15: 51-62.
Gori S, Morelli N, Maestri M, Fabbrini M, Bonanni E, Murri L. Sleep quality, chronotypes and preferential timing of attacks in migraine without aura. J Headache Pain 2005; 6: 258-260.
Hsu LK, Crisp AH, Kalucy RS, Koval J, Chen CN, Carruthers M, Zilkha KJ. Early morning migraine. Nocturnal plasma levels of catecholamines, tryptophan, glucose, and free fatty acids and sleep encephalographs. Lancet 1977; 1(8009): 447-451.
International Headache Society. The International Classification of Headache Disorders, 2nd edition. Cephalalgia 2004; 24 (suppl. 1): 1-160.
Schönhammer R. 'Typical' dreams. Reflections of arousal. Journal of Consciousness Studies 2005; 12 (4-5): 18-37.
Schondorf R, Low PA. Idiopathic postural orthostatic tachycardia syndrome: an attenuated form of acute pandysdautonomia? Neurology 1993; 43: 132-137.

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