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Letter to the Editor
 Sleep Bruxism as a Contributing Factor to Morning Headache: A Response to Recent Commentary
Yooha Hongorcid, Hee-Jin Imorcid

DOI: https://doi.org/10.62087/hpr.2026.0020
Published online: June 18, 2026

Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea

Correspondence: Hee-Jin Im, M.D., Ph.D. Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7 Keunjaebong-gil, Hwaseong 18450, Republic of Korea Tel: +82-31-8086-3185, Fax: +82-31-8086-2317, E-mail: coolere@naver.com
• Received: May 7, 2026   • Accepted: May 7, 2026

© 2026 The Korean Headache Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Dear Editor,
We sincerely thank the authors for their thoughtful and insightful comments on our recent review of morning headache.1,2 We greatly appreciate their interest in our work and their valuable contribution in highlighting the potential role of sleep bruxism (SB) as an underrecognized factor in morning headache.
We agree that SB is an important and often overlooked sleep-related motor activity that may contribute to morning headache. Repetitive masticatory muscle activity during sleep may cause muscle overload and activate myofascial pain mechanisms. In addition, SB has been associated with microarousals and transient autonomic activation, which may disrupt sleep architecture and lower the nociceptive threshold, potentially contributing to headache upon awakening.3,4
We also acknowledge emerging evidence from polysomnographic and observational studies suggesting an association between SB and wake-up headache.4 The interaction between SB and obstructive sleep apnea (OSA) is also clinically relevant, as the two conditions share mechanisms such as sleep fragmentation and autonomic dysregulation.5,6 From a neurological perspective, incorporating SB into the diagnostic framework for morning headache may improve clinical evaluation, particularly in patients with otherwise unexplained symptoms.
At the same time, we emphasize that current evidence remains insufficient to establish a clear independent causal relationship between SB and morning headache. Many studies have used cross-sectional designs, and heterogeneity in SB assessment methods may influence the observed associations. Therefore, SB may be better conceptualized as one component of a multifactorial model of morning headache rather than as a standalone etiology.7,8
In addition to SB itself, SB frequently coexists with temporomandibular disorders (TMD), a well-recognized cause of orofacial pain and headache.9 Clinical features such as jaw pain, joint sounds, and restricted mandibular movement may indicate underlying TMD, which may itself contribute to morning headache. Notably, laboratory-based polysomnographic studies suggest that pain outcomes may be more strongly associated with coexisting TMD than with SB alone.7 Therefore, TMD should be carefully assessed before morning headache is attributed directly to SB.
In conclusion, we appreciate the authors’ important perspective and agree that SB should be considered in the broader diagnostic approach to morning headache. As neurologists, we will incorporate SB assessment into the clinical evaluation when appropriate. However, comprehensive assessment, including evaluation for OSA, insomnia, and TMD, remains essential, and further research is needed to clarify the independent role of SB in headache pathophysiology.
We thank the authors again for their valuable comments and for contributing to a more nuanced understanding of this clinically relevant topic.
  • 1. Hong Y, Kang MK, Kim MS, Mo H, Cox RC, Im HJ. Morning headaches: an in-depth review of causes, associated disorders, and management strategies. Headache Pain Res 2025;26:66-79.ArticlePDF
  • 2. Kim ST. Comments on “Morning headaches: an in-depth review of causes, associated disorders, and management strategies”. Headache Pain Res 2026 May 29 [Epub]. https://doi.org/10.62087/hpr.2026.0014.Article
  • 3. Lavigne GJ, Khoury S, Abe S, Yamaguchi T, Raphael K. Bruxism physiology and pathology: an overview for clinicians. J Oral Rehabil 2008;35:476-494.ArticlePubMed
  • 4. Vieira KRM, Folchini CM, Heyde MDVD, Stuginski-Barbosa J, Kowacs PA, Piovesan EJ. Wake-up headache is associated with sleep bruxism. Headache 2020;60:974-980.ArticlePubMedPDF
  • 5. Hosoya H, Kitaura H, Hashimoto T, et al. Relationship between sleep bruxism and sleep respiratory events in patients with obstructive sleep apnea syndrome. Sleep Breath 2014;18:837-844.ArticlePubMedPDF
  • 6. Lavigne GJ, Huynh N, Kato T, et al. Genesis of sleep bruxism: motor and autonomic-cardiac interactions. Arch Oral Biol 2007;52:381-384.ArticlePubMed
  • 7. Raphael KG, Sirois DA, Janal MN, et al. Sleep bruxism and myofascial temporomandibular disorders: a laboratory-based polysomnographic investigation. J Am Dent Assoc 2012;143:1223-1231.ArticlePubMedPMC
  • 8. Lobbezoo F, Ahlberg J, Glaros AG, et al. Bruxism defined and graded: an international consensus. J Oral Rehabil 2013;40:2-4.ArticlePubMedPDF
  • 9. Svensson P, Jadidi F, Arima T, Baad-Hansen L, Sessle BJ. Relationships between craniofacial pain and bruxism. J Oral Rehabil 2008;35:524-547.ArticlePubMed

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      Sleep Bruxism as a Contributing Factor to Morning Headache: A Response to Recent Commentary
      Sleep Bruxism as a Contributing Factor to Morning Headache: A Response to Recent Commentary
      Headache and Pain Research : Headache and Pain Research
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