Sleep and Chronic Pain: Strategies for Better Rest

Key Takeaways

Pain and poor sleep create a vicious cycle—each makes the other worse
Improving sleep can significantly reduce pain perception
Sleep hygiene and CBT-I are effective, evidence-based approaches
Most people with chronic pain have some sleep disturbance

The Pain-Sleep Connection

Pain and sleep have a bidirectional relationship—poor sleep increases pain sensitivity, and pain disrupts sleep. This creates a cycle that can be difficult to break but is crucial to address for effective pain management.¹

50-80%

of chronic pain patients report sleep disturbances²

How Poor Sleep Affects Pain

Increases pain sensitivity (hyperalgesia)
Reduces pain threshold
Impairs pain inhibition systems
Increases inflammation
Worsens mood and coping ability
Reduces healing and recovery

How Pain Affects Sleep

Difficulty falling asleep
Frequent awakenings
Less deep (restorative) sleep
Non-restorative sleep
Early morning awakening
Increased time in light sleep stages

Common Sleep Problems with Pain

Insomnia

Difficulty falling asleep (sleep onset insomnia)
Difficulty staying asleep (sleep maintenance insomnia)
Waking too early
Most common sleep disorder with chronic pain

Non-Restorative Sleep

Getting sleep but not feeling rested
Common in fibromyalgia and other conditions
Related to reduced deep sleep

Sleep Apnea

More common in those with chronic pain
Can worsen pain and fatigue
May be worsened by opioid medications
Requires specific diagnosis and treatment

Restless Legs Syndrome

Urge to move legs, especially at night
More common with fibromyalgia, neuropathy
Disrupts sleep onset and maintenance

Sleep Hygiene

Basic practices that support good sleep:³

Schedule and Routine

Consistent wake time (most important)
Consistent bed time
Relaxing pre-sleep routine
Limit naps to 20-30 minutes if needed

Sleep Environment

Cool temperature (65-68°F ideal)
Dark room (blackout curtains, eye mask)
Quiet (white noise if helpful)
Comfortable mattress and pillows
Reserve bed for sleep and intimacy only

Daily Habits

Morning light exposure
Regular physical activity (not too close to bedtime)
Limit caffeine, especially after noon
Avoid alcohol (disrupts sleep quality)
Don't eat heavy meals close to bedtime

Evening Routine

Dim lights 1-2 hours before bed
Limit screens (or use blue light filters)
Relaxation practices (reading, gentle stretching)
Wind-down time away from work/stress

CBT for Insomnia (CBT-I)

The gold-standard treatment for chronic insomnia:⁴

What Is CBT-I?

Structured program addressing thoughts and behaviors
More effective than sleep medications long-term
No side effects
Benefits persist after treatment ends
Effective even with chronic pain

Components

Sleep restriction: Temporarily limiting time in bed
Stimulus control: Rebuilding bed-sleep association
Cognitive therapy: Addressing unhelpful sleep thoughts
Relaxation training: Reducing physical tension
Sleep hygiene education: Optimizing habits

Access to CBT-I

Sleep psychologists or trained therapists
Online programs (some evidence-based)
Apps (Sleepio, CBT-I Coach)
Usually 4-8 sessions

Pain-Specific Sleep Strategies

Positioning

Pillows to support painful areas
Pillow between knees for back/hip pain
Elevated head for neck issues
Body pillow for full-body support
Experiment with positions

Mattress and Bedding

Medium-firm mattress often best for back pain
Consider mattress toppers
Temperature-regulating bedding if hot flashes/sweats
Adjustable beds for some conditions

Managing Pain at Bedtime

Timing of pain medications
Gentle stretching before bed
Heat or cold therapy
Relaxation techniques
TENS unit before sleep

When Pain Wakes You

Have a plan ready (medication, ice/heat)
Avoid fully waking—keep lights dim
Use relaxation to fall back asleep
If can't sleep after 20 minutes, get up briefly

Medications and Sleep

Sleep Medications

May help short-term but not long-term solution
Can cause dependence and rebound insomnia
CBT-I more effective long-term
Discuss with healthcare provider

Pain Medications Affecting Sleep

Opioids: Can disrupt sleep architecture, worsen sleep apnea
Some antidepressants: May help or hurt sleep
Steroids: Often disrupt sleep
Some NSAIDs: May affect sleep in some people

Medications That May Help Sleep and Pain

Some antidepressants (tricyclics, trazodone)
Gabapentin/pregabalin (for neuropathic pain)
Muscle relaxants (short-term)
Discuss timing and options with provider

Over-the-Counter Sleep Aids

Antihistamine sleep aids (diphenhydramine, doxylamine) are not recommended for regular use, especially in older adults. They can cause daytime drowsiness, cognitive issues, and are not effective long-term. Melatonin may help some people but timing and dose matter.

Relaxation for Sleep

Techniques

Progressive muscle relaxation
Deep breathing exercises
Body scan meditation
Guided imagery
Autogenic training

When to Practice

Part of wind-down routine
In bed if having trouble falling asleep
When waking during the night
Also practice during the day to build skill

When to Seek Help

See a Provider If

Sleep problems persist despite self-help strategies
Snoring, gasping, or breathing pauses during sleep
Severe daytime sleepiness
Restless legs significantly impacting sleep
Sleep problems worsening pain significantly

What to Expect

Sleep history and questionnaires
May recommend sleep study
Referral to sleep specialist or psychologist
Review of medications affecting sleep

Learn About Stress Management

Stress and sleep are closely connected.

Stress Management Guide

References

Finan PH, Goodin BR, Smith MT. The association of sleep and pain: an update and a path forward. J Pain. 2013;14(12):1539-1552.
Tang NK, Wright KJ, Salkovskis PM. Prevalence and correlates of clinical insomnia co-occurring with chronic back pain. J Sleep Res. 2007;16(1):85-95.
Irish LA, Kline CE, Gunn HE, et al. The role of sleep hygiene in promoting public health: A review of empirical evidence. Sleep Med Rev. 2015;22:23-36.
Vitiello MV, Rybarczyk B, Von Korff M, Stepanski EJ. Cognitive behavioral therapy for insomnia improves sleep and decreases pain in older adults with co-morbid insomnia and osteoarthritis. J Clin Sleep Med. 2009;5(4):355-362.

Sleep and Chronic Pain