Gregory Amatrudo, PsyD, finds that treating comorbid sleep disorders first can lead to relief from chronic headaches and migraines.

By Sree Roy

Headaches and sleep disorders are frequently comorbid. Gregory Amatrudo, PsyD, uses the bidirectional relationship to his patients’ advantage.

Employed by the Headache Center at Jefferson Health in Philadelphia, Amatrudo uses behavioral sleep medicine (BSM) approaches with his headache/migraine patients before deploying pain psychology—a unique two-pronged approach that earned him the Society of Behavioral Sleep Medicine 2023 Award for Outstanding Innovation in BSM Service Delivery.

“We know in individuals with headache or migraine, there is an intense amount of dysregulation—when it comes to their sleep, their pain, and their mood,” Amatrudo says. Behavioral sleep medicine techniques that help regulate sleep and align circadian rhythms mean people with headaches function better.

Gregory Amatrudo, PsyD
Gregory Amatrudo, PsyD

Comprehensive Assessment

Amatrudo’s headache patients begin with a comprehensive assessment that includes:

Insomnia and Headaches

Insomnia is the most common sleep disorder that Amatrudo encounters in headache/migraine patients. He treats it with cognitive behavioral therapy for insomnia (CBT-I), including sleep restriction and bright light therapies, occasionally with supplemental melatonin. “Sleep restriction is not sleep deprivation, but rather it is changing the time that a person is spending in bed to align more with their circadian rhythm,” he says.

Circadian Rhythm Disorders and Headaches

Circadian rhythm sleep disorders are also prevalent. “I see a lot of 20-somethings with headache/migraine who cannot fall asleep until 2 am, do not wake up until noon, and who do poorly in their college classes,” Amatrudo says. If they simply wake earlier, their headaches worsen. “This is where we see that bidirectional relationship, and why I use a two-pronged approach,” he says.

That means treating a patient’s circadian rhythm sleep disorder first, potentially including chronotherapy, low-dose melatonin, and blue light-blocking glasses. “I’ve had significant success with individuals not only altering their circadian rhythms but also experiencing fewer headaches and enhanced daytime functioning,” he says.

Sleep Apnea and Headaches

Sleep apnea is also linked with headaches. People with sleep apnea and comorbid insomnia can sometimes surprisingly lower their sleep apnea severity through CBT-I. (Of course, people with moderate to severe sleep apnea also need device-based therapies or surgery.)

“For these people on the cusp of a sleep apnea diagnosis, who maybe have some snoring, we can try sleep restriction,” Amatrudo says. “There’s been some research to show that it could help with sleep-disordered breathing.”

One such study found that CBT-I promotes a 15% decrease in sleep apnea severity in patients with comorbid insomnia, possibly because it consolidates periods of sleep and reduces sleep–wake transitions to improve airway stability.1

For all of these comorbid sleep disorders, the behavioral sleep prong of the treatment can be brief for many headache patients. “One to three sessions can help a person make tremendous clinical gains,” Amatrudo says.


1. ​​Sweetman A, Lack L, McEvoy RD, et al. Cognitive behavioural therapy for insomnia reduces sleep apnoea severity: a randomised controlled trial. ERJ Open Res. 2020 May 17;6(2):00161-2020.

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