Tonsillectomy for the Treatment of Suspected Sleep Apnea with Subsequent Improvement of Chronic Migraine

Obstructive sleep apnea (OSA) is a highly prevalent sleep disorder, affecting more than 1 billion individuals worldwide¹ and 20% to 90% of people who are referred for sleep studies.² Patients with sleep apnea experience cycles of disrupted or ceased breathing during sleep, which can be caused by increased airway resistance of respiratory passages.² Comorbidities associated with OSA include cardiac arrhythmias, depression, and hypertension.^2,3

Tonsil hypertrophy can contribute to increased airway resistance and tonsillolith formation (tonsillithiasis) because of calcification of anaerobic bacterial aggregates, cellular debris, and food particles within the invaginated tonsillar crypts of the palatine tonsils,⁴ resulting in halitosis and periodic tonsillitis. Increased airway resistance is a major risk factor for OSA (Figure 1). According to the literature, tonsilloliths and acute tonsillitis with peritonsillar abscesses can contribute to snoring, dyspnea, and sleep-disordered breathing caused by upper airway obstruction.^4-6

Tonsillectomy involving surgical removal of the palatine tonsils is performed commonly as a treatment for this condition in the pediatric population but is less commonly performed in adult populations despite low postoperative hemorrhage and infection rates of 1% to 7%.⁷ This procedure is performed mainly to treat recurring or chronic tonsillitis in adults, limiting the potential benefit of surgery for treating other indications such as sleep disorders.⁷ There is a positive correlation between tonsil grade and the apnea-hypopnea index (AHI) in homogenous adult cohort studies worldwide as well, suggesting that tonsil size plays an important role in adult OSA diagnosis.⁸ A meta-analysis of 17 studies demonstrated a decrease in AHI by 65.2% and a reduction in Epworth Sleepiness Scale score from 11.6 ± 3.7 to 6.1 ± 3.9 when treating OSA with tonsillectomy among adults with tonsil grade 2 to 4 who have mild to moderate OSA.⁹

According to the International Classification of Headache Disorders, 3rd edition (ICHD-3), sleep apnea can be a cause of headache or a trigger for the chronification of migraine. Adequate treatment of sleep apnea can result in improvement of migraine frequency and intensity. Headache disorders, including migraine, are a prevalent cause of disability worldwide, affecting an estimated 3 billion individuals worldwide according to various sources, including the Global Burden of Disease studies.¹⁰ The World Health Organization ranks headache disorders as one of the 10 most disabling conditions regardless of sex, indicating a need for more effective treatments.¹¹ Sleep parasomnias can be a major trigger or cause of chronic morning headache and can contribute to the transformation from episodic to chronic migraine.¹²

Several polysomnographic studies indicate a strong association between OSA-derived sleep disturbances and bilateral headache development.³ A population-based study screened 12,810 adults and determined that people with chronic migraine (51.8%) were at a higher risk for OSA than people with episodic migraine (35.65%), suggesting a bidirectional relationship between migraine attack frequency and sleep disorders.¹³ Poor sleep may contribute to migraine chronification by a reduction of the glymphatic system’s ability to mitigate the destabilizing activity of abnormal beta-amyloid proteins in the central nervous system.¹³

Case Presentation

A 24-year-old woman with a history of obesity (height, 5’0”; weight, 195 lbs; body mass index, 38.1) and asthma presented with a 9-year history of headaches, which had been worsening in frequency and intensity over time. She denied any trauma, illness, or other events that may have triggered her headaches at the time of onset. She estimated having 15 to 20 headache days per month, with attack durations potentially lasting multiple days, and frequent morning headaches upon awakening. These throbbing headaches originated around the right temple, and when severe, were holocranial, with a pain level rated as 8 out of 10 (with 1 to 3 out of 10 indicating mild pain with no change in function; 4 to 6, moderate pain with reduced ability to function; and 7 to 10, severe pain with inability to function).

The headaches involved photophobia, phonophobia, nausea, cutaneous allodynia, and vomiting. She reported that position change, physical activity, coughing, and sneezing worsened a headache but did not trigger one. She denied visual, sensory, motor, or language aura and noted that headache frequency and intensity increased around the time of menses. Based on the patient’s history, her headaches met ICHD-3 criteria for chronic migraine without aura.

The patient reported sleeping 9 to 10 hours per night, but she was waking up 3 to 5 times per night. She woke up feeling poorly rested and experienced excessive daytime drowsiness on a regular basis. She also noted a history of heavy snoring and tonsillolith production. Her neurologic examination was unremarkable, but enlarged tonsils that were approximately 2.5 cm in diameter were noted during her physical examination. Given her sleep history suggestive of undiagnosed sleep apnea, large tonsils, and tonsillolith formation, an otolaryngology referral was generated, rather than a sleep medicine consultation.

The patient subsequently underwent a bilateral tonsillectomy. Her right tonsil was cerebriform measuring 3.0 x 2.1 x 1.5 cm, and her left tonsil was cerebriform measuring 3.1 x 2.2 x 1.4 cm. After surgery, overnight oximetry was performed in the hospital and was within normal limits. One month after surgery, she had a follow-up appointment in the headache clinic, and a telephone follow-up appointment 5 months later. After tonsillectomy, she denied any further sleep interruptions and experienced a significant improvement of her daytime drowsiness. She denied any further tonsillolith formation. In addition, her migraine regressed from chronic migraine to low-frequency episodic migraine. She was consistently experiencing fewer than 5 headache days per month after surgery, which was a significant reduction from her previous frequency of 15 to 20 headache days per month.

Discussion

In cases involving a high index of suspicion of sleep apnea with chronic headaches that tend to occur upon awakening and large tonsils on physical examination, a referral for tonsillectomy evaluation should be considered. A surgical reduction of airway resistance through a relatively safe, potentially same-day surgical procedure like a tonsillectomy can be an effective treatment option for adults with mild to moderate OSA (AHI 5 to 30).⁹

Our patient experienced resolution of her sleep interruptions and substantial improvement in her daytime drowsiness after surgery. In addition, her headache frequency improved from 15 to 20 headache days per month to 5 or fewer headache days per month. Although such dramatic results may not be universally reproducible, tonsillectomy may be worth pursuing, considering the potential improvement of sleep, headaches, and tonsillolith formation, as was the case in our patient.

Tonsillectomy, although largely performed in adults for tonsillitis, can be useful as an alternative therapy for sleep-disordered breathing and OSA. Tonsillotomy has gained popularity among OSA treatments in the pediatric population. It involves subtotal (intracapsular) removal of the tonsils, and current literature demonstrates that it is relatively safe and associated with faster recovery time, less postoperative pain, less analgesic use, and lower incidence of postoperative hemorrhage in children compared with adults.¹⁴ Similar efficacy of tonsillotomy has been noted in adult cohort studies and may be preferred because natural involution of tonsil tissue is expected, lessening the chance of regrowth,⁷ but additional controlled studies are necessary to make a more definitive choice of one surgical option over another in adults. Even with improvement of symptoms, if individuals continue to have symptoms suggestive of sleep apnea after tonsillectomy, further evaluation with a sleep study should be considered. A weakness of this report is that the patient did not have a sleep study before her tonsillectomy, which was not performed because of high index of suspicion of sleep apnea.

Conclusion

In patients with a history of snoring, sleep interruptions, feeling poorly rested upon awakening, excessive daytime drowsiness, frequent tonsilitis, tonsillolith formation, and halitosis, visualization of the posterior pharynx should be incorporated into the physical examination. Tonsillectomy is a well-tolerated surgical procedure that can reduce airway resistance in people with suspected OSA. If the individual has migraines, improvement of migraine frequency and intensity may occur.

Key Messages

• In people who report snoring, sleep interruptions, feeling poorly rested upon awakening, excessive daytime drowsiness, frequent tonsilitis, tonsillolith formation, and halitosis, visualization of the posterior pharynx should be incorporated into the physical examination, and tonsillectomy should be considered.
• Tonsillectomy can help reduce airway resistance, frequent tonsilitis, and tonsillolith formation with associated halitosis.
• Reduction of airway resistance can result in improvement of suspected sleep apnea.
• Improvement of sleep quality, especially when there is a high suspicion for sleep apnea, may result in improvement of migraine frequency and intensity.