health

Sleep

Insomnia affects one third of the UK population.  That’s a staggering number of people who suffer with difficulties sleeping.  Insomnia is defined as a difficulty getting to or sustaining sleep or not having good quality sleep all of which cause problems with daily functioning (namely concentration), low mood or day-time sleepiness.  In a nutshell it’s poor quality sleep and it has a big impact on people’s lives. It is thought that 10-50% of patients seen by GPs suffer with insomnia.  When you run a search using “insomnia” as your criteria a multitude of papers with slightly alarming titles come up:

“insomnia increases risk of heart attacks and stroke”

“insomnia is linked to risk of gestational diabetes”

“insomnia increases risk of developing asthma”

The list goes on.  So aside from affecting peoples psychological health and ability to function it is also linked to some pretty serious health problems.  Therefore, it’s a big deal.

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I’d agree with the statistic above: at least one patient a day visits me to talk about difficulties sleeping and more tend to mention it as an also-ran when discussing their other health problems.  It’s a diagnostic feature of depression (early-morning wakening) as well as a key feature of anxiety (waking up in the night, difficulty getting to sleep) but given the fact that lack of sleep causes mood problems which one comes first?  Or is it just a vicious cycle?  If the long-term effects are so serious what can we do about it?  And why are GPs so reluctant to prescribe sleeping pills?

Causes

The causes of insomnia are seemingly never-ending.  As mentioned above, the most common cause is anxiety and depression affecting almost half of patients experiencing sleep difficulties.  One cause is the presence of another medical condition such as asthma (if it’s badly controlled people tend to cough at night), thyroid disorders, pain due to joint disorders and heart problems which leads nicely to the next cause: medications that we give to treat these conditions.  Anti-depressants can cause sleep problems as can medications used to treat asthma such as salbutamol (commonly known as the reliever inhaler) and steroids which are used for the treatment of asthma and other inflammatory conditions.  As well as drugs we give, drugs (legal or otherwise) that people choose to take recreationally can also cause insomnia.  I include caffeine, alcohol and nicotine in this list.  Then there are the sleep disorders…

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Sleep Disorders

The most common of these is obstructive sleep apnoea.  This is a condition where the air-ways become blocked for a period of time.  The person appears to stop breathing and the lack of oxygen causes them to rouse partially so the airways can open again.  Understandably this does not result in a  great nights sleep and people can feel very drowsy during the day, falling asleep more readily than is normal.  This condition can be assessed before you go and see a doctor: snoring is an almost universal feature of this condition but partners often report frightening “pauses” in breath.  If this is the case it’s worth doing the Epworth Sleepiness Scale.  If the score is over 10 a referral should be made to a sleep clinic for further assessment.  Before it gets to the stage of requiring machines to help keep the airways open overnight (CPAP) or devices to wear in the mouth, life-style changes like losing weight, stopping smoking, reducing alcohol intake and stopping sedative treatment can help.

Changes in the normal sleep pattern (Circadian rhythm disorders) such as jet-lag and shift work can cause insomnia.  This type of problem is characterised by difficulty going to bed at the same time as normal people do a sleeping longer with marked difficulty in waking.  And the final sleep disorders are parasomnias a group of disorders with include restless leg syndrome and sleep walking.  If no cause can be found then a diagnosis of “Primary Insomnia” is reached.

What can you do about your sleep

I often feel patients are disappointed the first time they come to see me about their difficulty sleeping.  Unfortunately there is no “magic bullet” many people desire.  Once I’ve assessed their sleep pattern and tried to ascertain a cause I usually talk about “Sleep Hygiene”.  This is the phrase we use to describe measures that can be adopted to promote good sleep and incorporates changes to the sleep environment and behaviour.

  1. The first thing to do is establish a routine.  Go to bed and wake up at the same time, this avoids the problem of oversleeping and the body often responds well to routine.  Developing a relaxing bed-time ritual (i.e. a cup of herbal tea followed by some reading time) can be beneficial.
  2. Avoid caffeine or alcohol 6 hours before bedtime and consider cutting it out altogether.
  3. Avoid screen use (TV, computer, mobile phone) for up to an hour before bed.  The light-rays from these screens is very stimulating and can delay sleep initiation.

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  1. Don’t take naps during the day
  2. Avoid exercise within 4 hours of bedtime but do exercise regularly during the day.
  3. Only use the bedroom for sleep (or sexual activity).  So if you can’t fall asleep and you’ve been trying for more that 30 minutes get up.  Also try to avoid doing work in the bedroom.  You are less likely to associated the room as a place of rest and this can result in trouble sleeping.

It has been reported that 30% of people improved with the above measures alone.  If none of these measures are beneficial and the problem has persisted for 4 weeks or more it is worth completing a sleep diary and seeing your GP as they may want to check for some of the conditions listed above.

What about sleeping tablets

Once upon a time doctors gave out sleeping tablets like they were going out of fashion.  Now you may have noticed we’re a lot more cautious.  I am sure I’m not alone in feeling wretched when I hear someone sit down and say “I’d like to have some sleeping pills” largely because I know they are likely to leave disappointed.  It’s not because we’re being difficult or trying to deprive people of that elusive good nights sleep, but the risks of taking hypnotics or sleeping pills far out-weigh the benefits.  Simply put: they’re dangerous.  And most of them are highly addictive.  If people have tried all the measures above, and they understand that medications are to be used as the exception, not the rule, I will advise that they can try over the counter medications.  These include the natural supplements and antihistamines you can get from the chemist.  If they fail I may prescribe a very limited prescription for a dreaded “Z” drug.  They can be useful when used for less that 4 weeks but they do not guarantee good sleep quality so the effects of insomnia may remain despite taking these pills.  The other issue is stopping them, they are addictive as I’ve said before, but they also cause a rebound-insomnia when they are stopped.  Unusual sleep behaviours have been reported on hypnotics such as “sleep driving” without remembering the event.

What will work?

If insomnia is caused by an underlying condition such as asthma or a heart problem, treatment of this should resolve the sleep difficulties.  Reduction in caffeine or alcohol at night will help with issues caused by stimulation from these drugs.  There are sleep therapies which can help.  The first is Cognitive Behavioural Therapy (CBT) which is a psychological talking therapy aimed at changing behaviour patterns.  Practitioners often employ techniques such as bedtime restriction.  This works by looking at the time spent in bed versus the time spent asleep using a sleep diary and restricting the time allowed in bed to the time spent asleep (for example if someone’s diary indicates they spend 8 hours in bed but only 6 hours asleep they should only spend 6 hours in bed).  This is usually started as a trial for 2 weeks and can be a very simple yet effective way of managing the problem.  In fact, the evidence shows that cognitive behavioural interventions work better than sleeping tablets in most cases.

As I said at the beginning, problems with sleeping are common and there are a myriad of causes for them.  Reaching for sleeping tablets is rarely recommended and often employing some of the changes above can make a real difference to peoples quality of life.

Exercise

Getting into exercise

Fitness is the new “hot-trend”.  You just have to scroll through Instagram to see a plethora of posts dedicated to home-based workouts, HIIT regimes, Weight Training, Running, swanky new exercises classes… the list is endless.  There are a multitude of health benefits to be gained from regular workouts including

  • Weight loss
  • Lowering the risk of heart attacks and strokes
  • Reducing blood pressure
  • Improving mental well being

Weight: obesity and overweight

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Weight loss is a lot of peoples main motivation for getting into exercise and for good reason.  Obesity is the most common nutritional disorder in the Western World.  According to Public Health England around 60% of people were overweight in the period between 2013-15 and one in four women were categorised as obese and trends show this problem is growing.  Obesity is one of those terms we all hate to use: it has negative connotations and often upsets people when they are labelled this way.  Essentially it means that a person is 20% heavier than their ideal body weight.  But what’s the problem?  Being overweight is not simply an “aesthetic” issue (although this can be what motivates some to change) but more importantly is a major health issue which can contribute to multiple long-term health problems like Type 2 Diabetes, heart attacks and strokes, high blood pressure, asthma, difficulties conceiving, psychological distress and depression, joint problems such as arthritis and cancer to name but a few.  The good news is that most of these health problems can be reversed by losing weight.  Great.  Simple.  Or is it?  Many people struggle to lose weight even when they are highly motivated.  It involves a complete shift in life-style: diet and exercise are both key components and it can seem daunting, time-consuming and expensive.  So where to start?

Benefits of exercise

Losing weight is often people’s goal but what if you’re already a healthy weight, why should you exercise?  In recent years there have been a few papers published in reputable journals like the British Medical Journal (BMJ) which extol the  benefits of exercising other than the aesthetic changes.  A study in October 2017 showed that the risk of developing depression can be reduced by 1-2 hours of exercise per week by 44%.  Another shows that one in 12 deaths can be reduced globally by between 1-2 hours per week and the risk of developing cardiovascular disease (heart attacks and strokes) can be significantly lowered.  And it’s even been linked to boosting “brain-power” in another study with one 45 minute session of “moderately intense exercise” advised in the over 50s per week.

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Getting Started

So we know why we should exercise and the benefits of regular training but how to we start, and where?  In January, thousands of people sign up to gyms with New Year deals and heads full of resolutions to “go to the gym”.  Very often, people do really well for the first couple of weeks and then they just stop.  There are loads of reasons for this: they don’t know what to do when they actually get to the gym, it’s boring when they’re there and often, it can be quite intimidating.  The gym works really well for some people, and obviously there are people who seem to spend their lives there (I’m fairly guilty of that) but there is no “one-size fits all” for exercise.  So here are my tips for where to start:

  • Find an activity that you enjoy: there’s no way any one will stick at anything they find boring or unpleasantly uncomfortable for any period of regularity so it’s best to think of group activities or exercises that you find fun.
  • Think outside the box: again, exercise is not just jogging, lifting weights, going to a class or (my personal nemesis) swimming, but can consist of activities that you can do in your daily life.  Such as walking or cycling to work, rock climbing, dance classes, team sports etc.

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  • Think about starting a fitness routine with a buddy: it’s very difficult to stay motivated if you’re going it alone.  It can be helpful to find a friend or family member to encourage you to keep going.
  • Have a goal: Targets are useful.  They give you something to work towards and keeps you motivated.  Just make sure that the initial target is achievable at first and then you can revise it and start to “think bigger” as time goes on.  Some people find it helpful to think of things like “I want to be able to fit into that dress I bought 3 years ago” but I tend to find goals such as “Aim to be able to run/swim/cycle 5-10km in a certain time-frame in 3 months”.

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  • Keep work outs varied where possible.  The body gets used to moving in certain ways so I have often found it useful to “mix-up” my work out routine.
  • Try and include some resistance training.  This can be the tricky one.  When people first start exercising the emphasis is generally on cardiovascular or aerobic type exercises like running, spinning, swimming.  This is a great way to initially build fitness and get into the routine of regular training but eventually it can be beneficial to add in weights (resistance training) in fact, the guidance is that we should all do more resistance training than cardio.  This can be quite a daunting prospect initially particularly for women: the fear of building muscle mass and becoming bulky stopped me from lifting weights for years, but the truth of the matter is, it’s very difficult for women to build muscle in that way and using weights in training is an efficient way to tone up and burn fats, thus making it ideal for improving the function of the heart and reducing blood pressure.

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If you think you may fall into the overweight or obese category I would advise you to see your GP.  They may want to assess your cardiovascular risk and check for any of the complications that I listed above.  In some areas the GP can also refer you to an exercise programme to help you get started with “exercise on prescription”.  Also check out the NHS website’s section on fitness for more information on how to get started and the guidelines for activity according to age-group.

Headache

Migraine

“I’ve come to see you about my headache.” It’s a phrase that leaves many GPs with a feeling of dread.  Headache is a bit of a nightmare.  Most people with a severe or new headache are terrified about the worst case scenario: Cancer.  Doctors worry about missing other critical headaches and, once they’ve been ruled out, trying to reassure the patient that the headache is unlikely to be sinister but…what do they do about it?  What’s the diagnosis?

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I have a vested interest in this subject.  I suffer with migraine with varying degrees of regularity.  If you’ve read my post about me you’ll know my Mum suffered with them and my sister does too.  I used to be appalling at managing them: I’d take a couple of paracetamol, which didn’t take the pain away, and pop myself in a dark room until the worst of it eventually eased enough for me to carry on with the merest semblance of my normal life.

I’ve suffered with migraine since I was 12.  I vividly remember my first attack.  I was in the school playground, queuing for lunch and I had felt a bit more tired that usual.  I felt like the sun was dazzling me (even though it was a typical cloudy, autumn day in England) and I couldn’t really see because bright spots were dancing in my field of vision.  Then my head was throbbing, not the worst pain I’d had, but it bothered me.  I couldn’t speak, the words just wouldn’t come out.  And it lasted for the rest of the day.  I told my Mum and she solemnly told me I’d had a migraine.

In my early 20s, when I was at medical school I sat in on a clinic with a GP who was headache specialist.  It changed my life.  I’m not exaggerating.  “Does anyone here suffer with migraine?” He looked at the four of us: two medical students, two GP-trainees.  I tentatively put my hand up.  He figured one out of four of us would suffer.  He asked what I did.  Did it work? No.  Why did I do it?  Had I seen my doctor?  No.  What was the point?  What could they do?  Apparently, quite a lot.  He gave me a little plan for what to take: Aspirin (who knew people still took that for pain?!), if that didn’t work I could try a “triptan” (more on these wonderful drugs later) and if I got them more than 4 times a month I should try a preventative medication.  And it worked.

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And ever since then, I’ve wanted to do the same: improve people’s migraines.

Migraine – what is it?

Migraine is the 7th most debilitating disease globally. The word Migraine comes from the Greek Hemicrania meaning half a head as historically it referred to pain which affected only affected one side.  Now it is defined as a pain which can affect one or both sides of the head which is often throbbing in nature with other troublesome features such as:

  • Light or sound sensitivity
  • Nausea or vomiting
  • Tiredness

There are many different migraine subtypes and people do not have to experience flashing lights or other visual changes to be diagnosed with this.  People that do have that symptom are described as having an “aura”.  Only 10-30% of people with migraine suffer aura.  Aura doesn’t have to be visual.  The symptoms of aura typically start before the headache people can get:

  • numbness
  • dizziness
  • problems speaking
  • memory loss
  • paralysis

The headache doesn’t always have to be severe.  This is the most common misconception.  Like with most problems you can get mild, moderate or severe attacks.  Often people can take a day or two to recover and a lot of people describe this as feeling like a hangover.

Migraine does not have to start when you’re young.  It often starts at puberty and commonly affects those between in their 20s and 30s.  It affects around 1 in 7 people and women are three times more likely to suffer than men.

What causes migraine?

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We don’t fully understand what happens during a migraine.  We know some of the substances that are involved in migraine (like serotonin and CGRP) which has helped with the development of some of the medicines used to treat it, but the full process is still a bit of mystery.  We also know that it runs in families with more that half of patients with migraine having a relative who also suffers.

Impact on society

Migraine is debilitating.  A lot of people find the headache bearable but try going to work and trying to carry on with

  • impaired vision
  • problems concentrating
  • feeling queasy
  • difficulty looking at a computer
  • not being able to sleep

It makes simple things like checking your emails or sitting through a presentation a mammoth task.  But people don’t like calling in sick for work.

“Surely you can come in… it’s just a headache”.

In the clinic I see people week on week referred in because work are concerned about their sickness absence and they give a sense that the patient is just… putting it on.

“Migraine leads to reduced productivity at work and has major implications for society”  NICE CKS

Migraine costs the UK economy an estimated £2.5 billion per year due to absenteeism.  It’s a big deal.

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How is it diagnosed?

The most frustrating thing about migraine is that there are no tests to confirm the diagnosis: we listen to the pattern, find out if the features above are present and make the diagnosis on that basis.

The best way of knowing whether or not you have a migraine and decide on the best course of treatment is to track it.  This can be done via countless apps or using a good, old fashioned diary.  The National Migraine Centre has a version here.

For more information please see:

The Migraine Trust

The National Migraine Centre

About Blog

About Me

Me

 

I am an NHS GP with a specialist interest in Headache, who works in South London.  I have three major passions in my life: exercise (or “training” as we’re supposed to call it now), promoting health and well-being and my family.  To be a good and effective GP takes time and life experience: I know that the events in my life have shaped what kind of doctor I have become.

 

I have always been lucky to be relatively healthy and have never needed to spend any significant time in hospital aside from trips to asses minor sports injuries and one (humiliating) A&E visit during medical school (where my Mum mistook a migraine for meningitis).  Aside from migraines, my immediate family had also always been similarly healthy until the Summer of 2012.  I was in my second year of being a fully-fledged doctor and I was in my first proper GP placement.  I have to admit at the time I hated GP because I was not in a sociable practice: people tended to work in silos isolated from each other and I had next to no support, despite having very little experience of being a doctor.  In retrospect the work I was expected to do was alarming given the lack of knowledge I had at that stage of my training.  The saving grace was that I was that I was living at home so after hours of isolation (which sounds odd when you spend all day seeing patient after patient) and mentally taxing work, it was wonderful to be able to relax and spend time with my parents.

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One night in July, my Mum woke in the night with a bad migraine.  This wasn’t particularly unusual: she’d always suffered with bad migraines fairly frequently and wasn’t keen on taking any kind of preventative treatment because she thought they were a sign that she needed to rest so if she got rid of them how would she know something was wrong?  She had the usual flashing lights, unbearable pain and panic attack she experienced with her migraines.  Unusually though, this one carried on… and on… for 5 days.  And she was being sick a lot.  On the 5th day I was stumped: I knew I was out of my depth and I told her to call her GP.  He visited her and she called me at 2pm saying he’d called an ambulance for her to go to hospital.  He thought she’d picked up a stomach bug and was dehydrated.  He’d said her blood pressure was low (she said it usually was) and that she had a heart murmur… had she had one before?  She had when my sister was born and the scan had shown that everything was fine.  He thought it was best she went in for some fluids and to get it checked out and he’d see her in a few days.  As soon as she told me she was going to hospital I burst into tears.  I was “on-call” that afternoon until 6.30 and one of only two doctors in the surgery.  They wouldn’t be happy with me leaving but I knew I couldn’t work while my Mum was in A&E.

When I arrived, my Mum had been taken straight to resus: the bit we always see on casualty where all the “exciting” stuff happens.  I knew this meant she was very unwell.  My dad and I waited in the relatives room until the nurse came to update us.  He told us there’d been some “changes on the ECG”.  I cut in, “what changes?”  He paused and I explained I was an F2 and he told me there was “ST elevation”: she’d had a heart attack.  A bit later the consultant came to talk to us: she’d admitted to some mild aching in her chest when the “migraine” started but put it down to the panic she often felt during an attack.  The ECG and blood test confirmed she’d has a massive heart attack 5 days previously.  Her organs had started to shut down.  Had we thought about resuscitation?  This was a massive shock.  My sister rushed up from London and we all went to speak to her once they’d finished their tests: hours after she’d arrived.  She was very calm and we caught up on the information they’d given us.  She told us to take my Dad home because it was far too late for him to be out so we agreed.  But could I remember to cancel her massage and hair appointments on Tuesday?  Those were the last words she said to me.

Me and Mum
Me and Mum

This sudden turn of events when I was in my mid-twenties, and, in my opinion, far too young to lose a parent, completely changed my life.  For the first time I experienced symptoms of anxiety and panic at very inconvenient times and, looking back, I was definitely depressed for at least a year.  This is all normal in the context of what happened.  I was determined to take control of my own health and well-being.  I didn’t want to feel low any more and I didn’t want to suffer the same heart problems my Mum had either.  So I started exercising regularly (sometimes, arguably too regularly)… and I’ve been hooked ever since.

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It’s also made me a better doctor.  I believe good health is far more than physical health (i.e. the absence of physical illness) but also ties in with emotional and psychological wellbeing; something which can easily be over-looked in an NHS under pressure.  Now more than ever, I think it’s vital that people (or “patients”) are empowered.  By that I mean have the knowledge and tools to cope with many of the health problems we all face day to day.  And that’s why I decided to write a blog…