Cognitive Behavioral Therapy for the Management of Episodic Migraine.

PURPOSE OF REVIEW: This article provides an overview of the application of CBT in the management of episodic migraine while also providing context and insight into the underlying neurophysiological mechanisms of therapeutic change. It discusses the theoretical foundations of CBT and highlights key components including education, cognitive restructuring, behavioral interventions, relaxation techniques, and lifestyle changes. RECENT FINDINGS: Cognitive behavioral therapy (CBT) is an empirically based treatment that is well suited for the management of episodic migraine. Although first-line treatments of migraine are typically pharmacological, a review of empirical literature suggests growing evidence for the use of CBT as a standard non-pharmacological treatment of headache conditions. In summary, this article explores evidence supporting the efficacy of CBT in reducing the frequency, intensity, and duration of migraine attacks as well as improving the quality of life and psychological well-being of those with episodic migraine.

The Hypersomnia Severity Index: reliability, construct, and criterion validity in a clinical sample of patients with sleep disorders.

STUDY OBJECTIVES: The Hypersomnia Severity Index (HSI) was designed to assess the severity and impairment of hypersomnolence and has been validated in persons with psychiatric disorders. Little is known about its psychometric properties in clinical samples of patients with sleep disorders. METHODS: One hundred fifty-eight patients (aged 44.1 ± 16.4 years, 29.1% male, 19.6% racial/ethnic minority) evaluated at the Behavioral Sleep Medicine program of the Penn State Health Sleep Research and Treatment Center completed the HSI and other patient-reported outcomes. We examined the HSI's reliability and factorial, construct, and criterion validity. RESULTS: The HSI showed satisfactory internal consistency (α = 0.79). A 2-factor structure, reflecting symptoms (HSI-S) and impairment, explained 56.2% of the variance. Convergent validity with the Epworth Sleepiness Scale was optimal (r = .65) but greater for HSI-S (r = .69) than for impairment (r = .39). Divergent validity was optimal for HSI-S against unrelated measures of sleep effort, reactivity, and incompatible behaviors (r ≤ .02). Construct validity showed higher scores in patients with central disorders of hypersomnolence and lower scores in patients with chronic insomnia disorder compared to those with other sleep disorders; however, these divergent scores were primarily driven by HSI-S rather than impairment. Criterion validity showed that an HSI-S cutoff score ≥ 8 provided the best balance in sensitivity/specificity (0.82/0.78) to identify central disorders of hypersomnolence (area under the curve, 0.85). CONCLUSIONS: The HSI shows satisfactory indices of reliability and validity in a clinical patient sample. Its construct and criterion validity are supported by its divergent association with other patient-reported outcomes and central disorders of hypersomnolence vs chronic insomnia disorder diagnoses and the adequate sensitivity/specificity of its HSI-S cutoff score to reliably identify central disorders of hypersomnolence. CITATION: Fernandez-Mendoza J, Puzino K, Amatrudo G, et al. The Hypersomnia Severity Index: reliability, construct, and criterion validity in a clinical sample with sleep disorders. J Clin Sleep Med. 2021;17(11):2249-2256.

Insomnia with objective short sleep duration is associated with cognitive impairment: a first look at cardiometabolic contributors to brain health.

STUDY OBJECTIVES: Insomnia with objective short sleep duration has been previously associated with adverse cardiometabolic health outcomes as well as poorer cognitive performance in otherwise noncognitively impaired adults. However, studies demonstrating an increased prevalence of cognitive impairment (CI) in this insomnia phenotype are lacking. METHODS: We analyzed data from Penn State Adult Cohort (N = 1,524; 48.9 ± 13.4 years; 53.4% women). Self-reported sleep difficulty was defined as normal sleep (n = 899), poor sleep (n = 453), and chronic insomnia (n = 172). Objective short sleep duration was defined as less than 6-h of sleep, based on in-lab, 8-h polysomnography. CI (n = 155) and possible vascular cognitive impairment (pVCI, n = 122) were ascertained using a comprehensive neuropsychological battery. Analyses adjusted for age, sex, race, education, body mass index, apnea/hypopnea index, smoking, alcohol, psychoactive medication, and mental and physical health problems. RESULTS: Participants who reported poor sleep or chronic insomnia and slept objectively less than 6 hours were associated with a 2-fold increased odds of CI (OR = 2.06, 95% confidence limits [CL] = 1.15-3.66 and OR = 2.18, 95% CL = 1.07-4.47, respectively) and of pVCI (OR = 1.94, 95% CL = 1.01-3.75 and OR = 2.33, 95% CL = 1.07-5.06, respectively). Participants who reported poor sleep or chronic insomnia and slept objectively more than 6 hours were not associated with increased odds of either CI (OR = 0.72, 95% CL = 0.30-1.76 and OR = 0.75, 95% CL = 0.21-2.71, respectively) or pVCI (OR = 1.08, 95% CL = 0.42-2.74 and OR = 0.76, 95% CL = 0.16-3.57, respectively). CONCLUSIONS: Insomnia with objective short sleep duration is associated with an increased prevalence of CI, particularly as it relates to cardiometabolic health (i.e. pVCI). These data further support that this insomnia phenotype may be a more biologically severe form of the disorder associated with cardiovascular, cerebrovascular, and neurocognitive morbidity.

Clinical Significance and Cut-Off Scores for the Pre-Sleep Arousal Scale in Chronic Insomnia Disorder: A Replication in a Clinical Sample.

Background: In contrast to pre-sleep cognitive arousal, self-reported pre-sleep somatic arousal is a rather elusive construct for which little validity has been provided. Thus, the clinical significance of somatic symptoms during the pre-sleep period remains unknown. Participants: 248 patients (45.0 ± 16.7 years old, 65.3% female) with a diagnosis of chronic insomnia disorder, out of 388 consecutive patients evaluated at the Behavioral Sleep Medicine (BSM) program of Penn State Hershey Sleep Research & Treatment Center. Methods: Participants completed the Pre-sleep Arousal Scale assessing cognitive (PSAS-C) and somatic (PSAS-S) arousal as well as the Insomnia Severity Index (ISI), Ford Insomnia Response to Stress Test (FIRST), Arousal Predisposition Scale (APS), and Depression Anxiety Stress Scale (DASS). Multivariable stepwise regression assessed which clinical factors were independently associated with greater PSAS-C and PSAS-S scores. Receiver operating characteristic analysis determined the predictive value for identifying sleep reactivity (FIRST≥18) and clinical anxiety (DASS-A ≥ 10) and clinically useful cutoff scores. Results: The strongest correlates of PSAS-S were DASS-A (ß = 0.64) and chronic pain (ß = 0.11), while those of PSAS-C were FIRST (ß = 0.29) and a history of stroke (ß = 0.10). A PSAS-S score of 14.8 (AUC = 0.87, 95%CI = 0.83-0.91) and a PSAS-C score of 24.5 (AUC = 0.82, 95%CI = 0.76-0.88) showed the best balance in specificity and sensitivity to identify clinical anxiety and sleep reactivity, respectively. Conclusions: Self-reported pre-sleep somatic symptoms are a marker of comorbid anxiety and, potentially chronic pain, impacting nighttime sleep. The optimal cutoff scores of 14 and 20 proposed herein can help clinicians with case formulation, with tailoring BSM treatments and their targets.