Sleep and MS: Strategies for Improving Your Zzz's
Sleep is a surprisingly complex process that is essential to maintaining health and wellness. Unfortunately, problems with sleep quantity and quality and the negative impact of poor sleep on daily functioning are particularly common among people with MS, affecting 50% of the population.1 Sleep disturbance may arise for a number of reasons, including MS disease activity. For example, sleep can be affected when MS lesions occur in areas of the brain that are responsible for governing sleep and circadian rhythms (i.e., sleep-wake cycles within a 24-hour period).2 Sleep problems can also occur as a consequence of the many co-occurring, or co-morbid, symptoms that go along with MS. Some of those uncomfortable symptoms include, but are not limited to, medication side effects, fatigue, and issues related to mood and/or anxiety. Lifestyle behaviors such as exercise and environmental factors such as bedroom characteristics (e.g., temperature, light, etc.) can also influence sleep.3 Compared to people without MS, people with MS are also at greater risk for developing medical conditions such as sleep apnea, periodic limb movements (PLMS), and restless legs syndrome (RLS), which interfere significantly with sleep quantity and quality.4
When possible, determining the cause of the sleep disturbance is an important, if not essential first step toward treatment. Although some some causes of sleep disturbance in MS are quite treatable, other causes may not be directly treatable. Thus, addressing the sleep disturbance itself may be helpful for reducing common MS symptoms like physical and cognitive fatigue, which are worsened by poor sleep.
MS symptoms that can cause or worsen sleep dysfunction:
- Depression: One of the most common symptoms of depression and anxiety is sleep disturbance. Depression is more common among people with MS than in the general population. Depression in this group can lead to insomnia (too little sleep), or hypersomnia (too much sleep).
- Stress and Anxiety: Many people have difficulty “turning their brain off” at night and falling asleep. This can be a sign that sources of stress or anxiety need to be addressed.
- Pain: Pain is a common MS symptom, and can make it extremely difficult to rest comfortably. Pain can come from nerve damage (neuropathic pain) as well as from prolonged periods of decreased mobility. Regardless of the cause of pain, people with MS and pain may experience difficulty falling asleep or maintaining sleep due to pain.
- Muscle Spasticity: In addition to being uncomfortable, spasticity can lead to jerking limb movements that can wake people up throughout the night. Spasticity can occur while one is awake and trying to fall asleep, or can occur during sleep, which is another type of sleep disorder.
- Bowel and Bladder Dysfunction: Getting up to use the bathroom several times a night can make it very difficult to get a restful night’s sleep.
- Temperature Sensitivity: Getting too hot or cold overnight can cause MS symptoms to worsen, leading to restless nights.
Medications and other substances that can affect sleep:5
- Antidepressants: Some antidepressants can cause insomnia if taken at night. Switching them to the morning can help significantly. Other medications for mood may cause drowsiness, which can then interfere with daytime functioning, increase napping, and indirectly interfere with sleep at night.6
- Stimulants: Medications used for fatigue including Amantadine, Modafinil, and Nuvigil, can cause insomnia if taken too late in the day.
- Steroids: Insomnia is a common (but temporary) side effect of corticosteroids, which are used to treat MS relapses. Sleep disturbance is usually resolved after completing the course of corticosteroids.
- Blood Pressure Medication: Certain types of medication used to treat high blood pressure can lead to insomnia and restlessness at night. Some blood pressure medications like “water pills” are diuretics and can increase urinary frequency at night.
- Alcohol: Although alcohol can make one feel sleepy or help one fall asleep, it can significantly interfere with quality sleep and does not support restorative sleep. Thus, it can lead to excessive daytime sleepiness.7
- Tobacco: Nicotine is a stimulant and can have a negative impact on sleep quality. Additionally, smokers have a higher incidence of insomnia, sleep apnea, and movements that can cause frequent awakenings at night.
- Caffeine: Caffeine found in coffee, tea, and soda can lead to insomnia if consumed too late in the day.
Environmental and lifestyle factors that can affect sleep
- Room temperature: Body temperature naturally decreases before we fall asleep. Sleep experts suggest keeping the bedroom cool, between 60-67 degrees Fahrenheit, to help your body initiate and sustain sleep.
- Sleep partners: We love our partners, children, and pets but they don’t always make the best roommates. Having a partner who snores or who has sleep apnea can interfere with sleep.
- Screens: Bright TV, phone, tablet, and computer screens suppress melatonin (a natural hormone that regulates our circadian rhythm), and trick our brains into thinking it’s daytime. Experts recommend turning them off for at least 30 minutes prior to bedtime, and keeping them off so that alerts do not continuously interrupt sleep throughout the night.
- Noise and Light: Making the bedroom as dark and quiet as possible helps facilitate sleep. Sleep masks and white noise machines can help people who live in cities or other noisy areas.
- Exercise: Getting enough physical activity during the day can help us fall asleep at night. However, because exercising makes your brain more alert some people find it difficult to fall asleep if they work out too close to bedtime.
- Comfort: Pillows, mattresses, sheets, and other bed linens can all affect your comfort at night. If you find yourself tossing and turning, or frequently wake up with back and neck pain it is time to splurge on new bedding.
- Naps During the Day: People with MS often experience fatigue and feel the need to nap and rest throughout the day. However, napping for too long (more than 1 hour) or too close to bedtime can affect nighttime sleep quality.
Treating sleep disturbance in MS can be challenging and can include: 1) treating the underlying causes of the sleep disturbance; and 2) treating the sleep disturbance itself. For example, if muscle spasticity is keeping you up at night, discussing strategies and medication options for reducing spasticity with your doctor may lead to significant improvements in sleep. The same goes for other common MS symptoms such as urinary/bowel dysfunction, and temperature dysregulation. Because insomnia is a side effect of several medications it is very important to bring it to the attention of your healthcare provider. Adjustments in medication dosages and schedule (i.e. taking a medication in the morning instead of at night) can be extremely helpful, and in some cases providers may even switch or stop certain medications
Depression, anxiety, and pain are also common causes of sleep disturbance that are highly treatable with behavioral interventions and may not require additional medication, although a combination of behavioral and pharmacological therapy has also been shown to be effective. For example, cognitive behavioral therapy (CBT) is a psychological treatment typically delivered by a psychologist or mental health professional that focuses on the thoughts and behaviors that underlie and maintain problems with mood and pain. Certain “catastrophic” thoughts (e.g., “I’m never going to sleep well again.”) or behaviors (e.g., excessive caffeine use) can exacerbate problems with depression, anxiety, and/or pain. CBT works to change and re-shape some of those unhelpful thoughts and promote healthier behaviors. CBT for insomnia (CBT-I) is a specialized type of CBT that specifically targets insomnia and can be effective in as little as 4-8 weeks. Meeting with a health psychologist or a behavioral medicine specialist may be an important step toward reducing sleep disturbance.
Sleep apnea is also more common in people with MS and is treatable. Continuous positive airway pressure (CPAP) is a common treatment for sleep apnea that helps maintain consistent flow of oxygen and reduce the interruptions in breathing that can cause significant health problems and poor sleep. CPAP machines have become much more sophisticated in recent years, to be quieter and less bulky with regard to the equipment.
People with MS often ask about the helpfulness of sleeping pills for insomnia. Much like alcohol, sedative medications can help with initiating sleep, but are not as helpful in maintaining sleep throughout the night. Additionally, most sedatives are only intended for short-term (few weeks) use and are not indicated for long-term use. Prolonged use of sleep medications can reduce their efficacy, where patients may find that after a few weeks of use, they are no longer effective. Additionally, some sedative medications can promote dependence, where it may become more difficult to sleep without them. An alternative over-the-counter medication, such as melatonin (a natural hormone released by the brain during sleep), may be recommended; however, there has not been sufficient research on melatonin in MS to determine its effectiveness.
Sometimes sleep dysfunction may not be obvious, especially if you don’t have trouble falling asleep. If you are experiencing any of the following symptoms you should discuss them with your health care provider:
- Excessive daytime sleepiness or fatigue
- Snoring at night
- Headaches in the morning
- Waking up early in the morning and not being able to fall back asleep
For more information, the National MS Society website has a page dedicated to sleep resources for people with MS. For more information, visit: http://www.nationalmssociety.org/Resources-Support/Library-Education-Programs/You-CAN!/Get-the-Sleep-You-Need!
- Bamer A, Johnson K, Amtmann D, Kraft G. Prevalence of sleep problems in individuals with multiple sclerosis. Mult. Scler. 2008;14(8):1127-1130.
- Melamud L, Golan D, Luboshitzky R, Lavi I, Miller A. Melatonin dysregulation, sleep disturbances and fatigue in multiple sclerosis. J. Neurol. Sci. 2012;314(1-2):37-40.
- Boe Lunde HM, Aae TF, Indrevag W, et al. Poor sleep in patients with multiple sclerosis. PLoS One. 2012;7(11):e49996.
- Braley TJ, Segal BM, Chervin RD. Obstructive sleep apnea and fatigue in patients with multiple sclerosis. J. Clin. Sleep Med. 2014;10(2):155-162.
- Foundation NS. What Causes Insomnia? 2016; https://sleepfoundation.org/insomnia/content/what-causes-insomnia, 2016.
- Dorsey CM, Lukas SE, Cunningham SL. Fluoxetine-induced sleep disturbance in depressed patients. Neuropsychopharmacology. 1996;14(6):437-442.
- Roehrs T, Roth T. Sleep, sleepiness, sleep disorders and alcohol use and abuse. Sleep Med. Rev. 2001;5(4):287-297.