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The destructive relationship between pain and sleep

By Dr Alison Bentley, Restonic Sleep Expert

The relationship between sleep and pain has been studied extensively. Not surprisingly, people who have pain often find it challenging to get enough sleep – in one survey, nearly half of patients with a pain condition complain of insomnia. Insomnia simply means not being able to get enough hours of sleep to function well during the day – whether it’s from difficulty falling asleep or waking up during the night and being unable to go back to sleep quickly. 

Other patients with pain complain of poor sleep quality – waking up after enough hours of sleep still feeling unrefreshed.

Snoring may be a sign of sleep apnoea. If your snoring is associated with daytime tiredness, catches or pauses in breathing at night, or high blood pressure, you should speak to your doctor about whether you possibly have apnoea.

A vicious cycle

We often assume that the sleep problem is caused by the pain only. However, recent research has shown that a poor night’s sleep results in increased pain the following day as well, thus creating a vicious cycle.

The link between pain and sleep

All sleep disorders, including sleep apnoea and restless legs syndrome, are more common in patients with pain. The implication from this is that it may be the sleep disorder creating poor quality sleep that started or worsened the painful condition, particularly if the pain is located in the muscles.

Fibromyalgia, for example, is a condition where the sleep-pain relationship is very closely linked and difficult to untangle.

Check your mattress

However, not all pain is the same when it comes to our relationship with sleep – or poor sleep. Waking up with back or neck pain may simply mean that and not supporting your body comfortably during the night. 

Waking up

If you wake regularly with headaches or jaw pain, ask your bed partner if you snore and appear to stop breathing, as these symptoms may indicate obstructive sleep apnoea. The repeated waking from apnoea can cause headaches and treating the sleep apnoea often relieves the headaches as well. People with migraines, despite the severe pain, often find it easy to fall asleep and also find that sleep helps to resolve their headaches.

Addressing the sleep issue

When deciding how to manage the combination of sleep and pain, we usually try and treat pain and assume the sleep problem will resolve after the pain has resolved. That is not going to happen if the sleep problem is due to sleep apnoea or restless legs syndrome. These two conditions need to be diagnosed properly and treated specifically – not with sleeping tablets – to improve sleep directly.

Better sleep after treatment of a sleep disorder may directly improve pain during the day.

Treating insomnia directly

Some good evidence now shows that treating insomnia directly, whether by a cognitive behavioural programme (CBT-I) or taking sleep medication, including hypnotics or melatonin, not only improves sleep but also improves daytime pain

Change your behaviour

CBT-I is the recommended treatment for insomnia, including changing your behaviours around sleep, such as shortening the length of time you spend in bed to take advantage of a consolidated sleep, and not lying in bed for hours trying to sleep.

Reflux

Often people who have pain go to bed early to rest, but this practice can make their sleep worse. The cognitive part of the programme may involve relaxation exercises to manage the anxiety from anticipating a poor night’s sleep. For those who are nervous about medications, this may be a better option.

Most people have more than one of these symptoms and they may not be specific for any particular cause.

When to be concerned?

If you are struggling with the pain/poor sleep combo, make sure that your treatment plan for pain includes a specific plan to tackle your poor sleep – particularly to exclude and treat specific sleep disorders. Tackling both sides of the problem may be needed to get full resolution of the pain.

Dr. Alison Bentley

Dr. Alison Bentley

Dr. Bentley is a medical doctor with 30 years of experience treating sleep problems in both adults and children. She has a PhD in restless leg syndrome and has worked in private practice, research including academia. She was the founding chair of the Sleep Society of South Africa and has presented at local and international medical and sleep conferences, and in her spare time, she volunteers to build nursery school classrooms. Dr. Bentley believes sleep remains under-researched and aims to improve sleep research and training for doctors. From 2023, Dr. Bentley will be partnering with Restonic SA to share her knowledge and expertise on sleep