Pain and sleep can become locked in a difficult relationship — and sometimes improving one can help the other

There is something particularly difficult about pain in the middle of the night.

During the day there are distractions. People to talk to. Things that need doing. You can change position, go for a walk, make a cup of tea or occupy your mind with something else.

At 3am, the world is very small.

There is you, the darkness, and the pain.

And it can feel enormous.

People living with persistent pain often tell me that sleep is one of the things they miss most. Some struggle to get comfortable enough to fall asleep. Others wake repeatedly because turning over hurts. Some sleep for a few hours and then find themselves wide awake in the early hours, unable to settle again.

By morning, they are exhausted.

Unfortunately, pain and sleep have a particularly unhelpful relationship.

Pain disrupts sleep — but poor sleep can also make pain worse.

Understanding that relationship can sometimes give us another way into a problem that has become very stuck.

Why does pain seem worse at night?

There isn't one explanation.

For some people, there is a straightforward physical reason.

Lying on an arthritic hip or painful shoulder may hurt. Certain spinal problems are uncomfortable in particular positions. Neuropathic pain can become particularly intrusive when someone is resting. Muscle spasm, restless legs, headaches and other conditions can all interfere with sleep.

But something else happens at night too.

The competing information of daytime life disappears.

During the day your brain is processing conversations, movement, traffic, work, food, television, other people and hundreds of small decisions.

At night much of that disappears.

Pain suddenly has the stage to itself.

That doesn't mean the pain is imagined or psychological.

It simply means that attention influences how strongly we experience sensation. Anyone who has suddenly noticed a headache after finishing a busy meeting has experienced a version of this.

Sleep itself changes how we experience pain

The relationship also works in the other direction.

When we sleep badly, our pain-processing systems change.

Even relatively short periods of disrupted sleep can increase sensitivity to painful stimuli. After repeated poor nights, things that were already painful may feel more painful, and our ability to cope with them can diminish.

This makes intuitive sense.

Think about how the world feels after several nights of inadequate sleep.

Noise is more irritating. Problems feel harder to solve. Emotions sit closer to the surface. Physical effort feels greater.

Pain is no different.

The nervous system is trying to manage pain while running on depleted resources.

So a difficult cycle can develop:

Pain disturbs sleep → poor sleep increases pain sensitivity → increased pain makes sleep harder → sleep deteriorates further.

After months or years, it can be difficult to know where the cycle began.

Fortunately, we don't necessarily need to know in order to start changing it.

This doesn't mean your pain is caused by poor sleep

This is an important distinction.

If someone has arthritis, nerve pain, hypermobility, spinal pain or pain following surgery, telling them to “sort out their sleep” can feel dismissive.

Better sleep doesn't make an injured or painful body magically normal.

But sleep is one of the systems that influences how much pain the brain and body have to cope with.

I sometimes think of it as turning the background volume up or down.

Improving sleep may not remove the source of pain, but it can sometimes make that pain easier to live with.

The pressure to sleep can become part of the problem

People with persistent pain often become understandably anxious about sleep.

You look at the clock.

11.30pm.

Then 12.45am.

Then 2.10am.

And a calculation begins.

If I fall asleep now, I can still get five hours.

Later:

Four hours.

Then:

I'm going to be exhausted tomorrow.

The harder we try to force sleep, the more alert we can become.

Sleep is unusual in that it is something we need to allow rather than something we can make ourselves do.

That is particularly difficult when you know that tomorrow's pain is likely to be worse if you don't sleep tonight.

Sometimes part of improving sleep is therefore reducing the battle with it.

What about “sleep hygiene”?

Most people with long-standing sleep problems have already heard the standard advice.

Keep the bedroom dark. Avoid caffeine late in the day. Don't spend hours on your phone in bed. Keep reasonably regular sleeping hours.

These things can help.

But telling someone who hasn't slept properly for three years to “avoid screens before bed” can feel rather inadequate.

Persistent insomnia often needs a more structured approach.

One of the best-established treatments is cognitive behavioural therapy for insomnia (CBT-I).

Despite the name, this isn't based on the idea that insomnia is “all in your head”. It uses practical strategies to help rebuild the association between bed and sleep, regulate sleep timing and reduce some of the behaviours that unintentionally perpetuate insomnia.

For persistent insomnia, it can be much more useful than endlessly adding bedtime rituals.

When the bed becomes associated with being awake

After months of difficult nights, something interesting can happen.

Bed stops being a strong cue for sleep.

Instead, it becomes the place where you lie awake, monitor pain, worry about tomorrow and try increasingly hard to fall asleep.

This association can become surprisingly powerful.

That is why some sleep treatments encourage people not to spend long periods lying awake in bed.

If you are wide awake and becoming increasingly frustrated, getting up for a while and doing something quiet in low light can sometimes be more helpful than remaining in bed fighting for sleep.

The aim is gradually to teach the brain again:

bed means sleep, rather than bed means hours of struggle.

Pain still needs treating

None of this replaces appropriate treatment of the pain itself.

If shoulder pain wakes you every time you roll onto one side, perhaps the shoulder needs assessing.

If severe nerve pain repeatedly wakes you, the treatment for the neuropathic pain may need reviewing.

If headaches regularly wake you from sleep, that may warrant investigation rather than simply being labelled poor sleep.

Sometimes changing the timing of medication can help. Sometimes physiotherapy, an injection or another treatment reduces the physical problem sufficiently to allow sleep to recover.

Good pain management and good sleep management should work alongside each other.

Medication and sleep

Many medicines used in pain medicine affect sleep.

Some, such as amitriptyline, may be deliberately taken at night because they can be sedating.

Gabapentin, pregabalin, opioids and other medicines may also cause drowsiness.

But sedation isn't quite the same thing as restorative sleep.

A medicine can make someone sleepy while still causing other problems, such as morning grogginess, impaired concentration or unsteadiness.

Some medications can also affect breathing during sleep, particularly when several sedating medicines are combined.

This is another reason why medication should be reviewed as a whole rather than simply adding another tablet because sleep is poor.

Sleeping tablets can have a role in selected situations, particularly for short periods, but they are rarely a complete long-term solution to persistent insomnia.

Don't forget sleep apnoea

Not every sleep problem in someone with chronic pain is caused by pain.

Obstructive sleep apnoea is common and often under-recognised.

Clues can include loud snoring, witnessed pauses in breathing, waking gasping or choking, morning headaches and significant daytime sleepiness despite apparently spending enough time in bed.

It is particularly important to consider when someone is taking opioids or other sedating medication.

If the story sounds suspicious for sleep apnoea, it deserves proper assessment.

Sometimes the goal isn't eight perfect hours

People can become very focused on achieving a particular number of hours of sleep.

Eight hours has almost acquired mythical status.

But sleep needs vary between individuals and across our lives.

A more useful goal may initially be:

more settled sleep, fewer prolonged awakenings and feeling more restored during the day.

Like pain management, improving sleep is often about function rather than chasing a perfect number.

What can you do when you're awake at 3am?

There is no magic technique that reliably switches sleep back on.

But there are ways of making those hours less distressing.

Try not to repeatedly check the clock.

Make yourself physically comfortable as far as possible — pillows, positioning, warmth or whatever usually helps your particular pain.

If you are clearly awake rather than drifting towards sleep, consider getting out of bed for a short period rather than fighting with it.

Keep the environment quiet and dim.

Do something undemanding.

And perhaps most importantly, try not to solve tomorrow at 3am.

A bad night is unpleasant.

It does not necessarily mean tomorrow will be a disaster.

Look at the whole night — and the whole person

When someone tells me they aren't sleeping because of pain, I don't think the answer should automatically be another sedating medicine.

I want to understand what is actually happening.

Is pain preventing you falling asleep?

Are you waking when you move?

Are you waking for another reason and then noticing the pain?

Are you snoring?

Are your legs restless?

Are hot flushes disturbing you?

Are you sleeping during the day because you are exhausted?

Has your medication changed?

Has something stressful happened in your life?

Different patterns need different solutions.

Sleep is part of pain treatment

When you live with persistent pain, sleep can begin to feel like collateral damage — another part of life that pain has taken away.

But I think it deserves to be considered as part of the treatment itself.

Sometimes treating the pain improves sleep.

Sometimes treating the sleep helps the pain.

Often we need to work on both.

The aim isn't to suggest that you could cure your pain if only you slept better.

It is much more practical than that.

If your nervous system has to manage pain every day, giving it better sleep may make that job a little easier.

And sometimes, that is enough to begin changing the cycle.