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The author thanks Dr. Rovers, Dr. Smits, and Dr. Duffy for their comments regarding the expert opinion article, Headache and Sleep.[1, 2] The evaluation of circadian rhythm disorders could play an important role in the management of migraine in patients with these disorders.[3] I believe that the methods suggested in our article, starting with the BEARS screening,[4] and if positive, proceeding with a more detailed sleep history, questionnaires, and sleep logs, would uncover most circadian disturbances. As pointed out by Rovers and colleagues, actigraphy could also be useful in confirming diagnosis.[1]

Melatonin has been shown to play a role in nociception in general,[5] including headaches.[6] Melatonin may have a role in the treatment of migraine in patients with circadian disorders. The results of Rovers et al are promising, but data from a placebo/control group were not shown.[1] A randomized controlled trial (RCT) duplicating these results would provide stronger evidence.

Prolonged released melatonin did not differ from placebo for the prevention of migraine in an RCT.[7] No other RCTs studying melatonin were cited in a recent guideline for prevention of migraine.[8]

The use of melatonin levels for dim light melatonin onset (DLMO) is efficacious in evaluating delayed sleep phase syndrome,[9] and melatonin is effective in managing this disorder.[10]

While I agree with the potential of melatonin in managing migraine in patients with circadian rhythm disorders, and that DLMO could be useful in migraine patients with suspected circadian disorders, it is not clear that the case has been made for routine monitoring of DLMO in all migraine patients.

References

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  2. References
  • 1
    Rovers J, Smits M, Duffy J. Headache and sleep: Also assess circadian rhythm sleep disorders. Headache. 10.1111/head.12217.
  • 2
    Freedom T, Evans RW. Headache and sleep. Headache. 2013;53:1358-1366.
  • 3
    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;6:58-60.
  • 4
    Owens JA, Dalzell V. Use of the “BEARS” sleep screening tool in a pediatric residents' continuity clinic: A pilot study. Sleep Med. 2005;6:63-69.
  • 5
    Srinivasan V, Lauterbach EC, Ho KY, Acuña-Castroviejo D, Zakaria R, Brzezinski A. Melatonin in antinociception: Its therapeutic applications. Curr Neuropharmacol. 2012;10:167-178.
  • 6
    Peres MFP. Melatonin, the pineal gland and their implications for headache disorders. Cephalalgia. 2005;25:403-411.
  • 7
    Silberstein SD, Holland S, Freitag F, Dodick DW, Argoff C, Ashman E. Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults: Report of the quality standards subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012;78:1337-1345.
  • 8
    Alstadhaug KB, Odeh F, Salvesen R, Bekkelund SI. Prophylaxis of migraine with melatonin: A randomized controlled trial. Neurology. 2010;75:1527-1532.
  • 9
    Rahman SA, Kayumov L, Tchmoutina EA, Shapiro CM. Clinical efficacy of dim light melatonin onset testing in diagnosing delayed sleep phase syndrome. Sleep Med. 2009;10:549-555.
  • 10
    Van Geijlswijk IM, Korzilius HPLM, Smits MG. The use of exogenous melatonin in delayed sleep phase disorder: A meta-analysis. Sleep. 2010;33:1605-1614.