Chronic Pain and Sleep: Understanding the Two-Way Relationship

Chronic pain and disturbed sleep often reinforce one another. Pain can make it difficult to fall asleep, remain asleep or find a comfortable position. Insufficient or fragmented sleep can then increase pain sensitivity and make symptoms feel harder to manage the following day.

Sleep disturbance is common among people with chronic non-cancer pain. One systematic review reported pooled estimates of approximately 73–75% using commonly used sleep questionnaires, although the figure varies according to the pain condition, population studied and definition of a sleep problem.[1–4]

Treating sleep does not mean that pain is imagined or “all in the mind”. Nor does it mean that improving sleep will remove the underlying cause of pain. It recognises that sleep is an important and potentially modifiable influence on pain sensitivity, mood, energy and daily function.

The pain–sleep relationship

Sleep and pain involve overlapping systems responsible for arousal, attention, emotional regulation, stress responses and the brain’s own pain-modulating processes. Experimental sleep loss can temporarily lower pain thresholds and reduce the effectiveness of endogenous pain inhibition—the nervous system’s ability to dampen incoming pain signals.[1,3]

Poor sleep can also increase fatigue, irritability, low mood and difficulty concentrating. These effects may make pain more intrusive, reduce coping capacity and make everyday activities feel more demanding. Changes in stress and immune signalling have also been observed following sleep loss, but their significance is complex and cannot be reduced to a single hormone, cytokine test or neurotransmitter imbalance in an individual patient.[1,3]

Although the relationship is often described as bidirectional, the two directions may not be equally strong. Longitudinal research suggests that sleep problems may precede the development or persistence of chronic musculoskeletal pain. Pain can also predict subsequent sleep problems, particularly over shorter periods, but the evidence for a long-term effect in this direction is less certain. In practice, both processes may still be relevant for an individual person.[1,2]

Not every sleep problem is insomnia

People living with chronic pain may experience several different sleep difficulties:

• Insomnia symptoms: difficulty falling asleep, repeated waking or waking earlier than intended, despite having enough opportunity to sleep.

• Non-restorative sleep: sleeping for an apparently adequate number of hours but waking feeling unrefreshed.

• Irregular sleep timing: substantial variation in sleeping and waking times, sometimes related to pain flares, inactivity, shift work or daytime sleeping.

• Obstructive sleep apnoea: repeated narrowing or closure of the upper airway during sleep, which may cause loud snoring, gasping, witnessed breathing pauses, morning headaches or excessive daytime sleepiness.

• Restless legs syndrome: an uncomfortable urge to move the legs, usually worse during rest and in the evening.

• Medication- or substance-related disruption: some medicines and substances can cause sedation, insomnia, abnormal movements, altered sleep architecture or sleep-related breathing problems.

Chronic insomnia is more than an occasional poor night. It generally involves difficulty falling or staying asleep, or waking too early, on at least three nights each week for three months or longer, despite adequate opportunity for sleep, together with meaningful daytime impairment.[8]

Fatigue and sleepiness are not identical. Fatigue refers to low energy or exhaustion. Sleepiness is a tendency to doze or fall asleep. Significant daytime sleepiness—particularly while driving or performing safety-sensitive work—requires clinical attention.

Why pain can disrupt sleep

Pain may wake someone directly or make it difficult to remain in one position. However, physical discomfort is often only one part of the problem.

Anticipating pain, monitoring symptoms and worrying about the consequences of another poor night can place the nervous system in a state of heightened arousal. Understandable attempts to compensate—such as going to bed unusually early, remaining in bed long after waking, sleeping late or repeatedly napping—can reduce the natural build-up of sleep pressure and unintentionally perpetuate insomnia.

Depression, anxiety, trauma-related arousal, menopause, other medical conditions and medication effects may also contribute. These factors should not be interpreted as evidence that pain is psychological; they are additional influences on two complex and interacting biological processes.[3,8]

What can help?

1. Identify the sleep problem

It is useful to assess sleep separately rather than assuming that every sleep difficulty is simply a consequence of pain. A sleep history—and sometimes a one- or two-week sleep diary—can help clarify:

• usual sleeping and waking times;

• how long it takes to fall asleep;

• the frequency and duration of awakenings;

• naps and time spent resting in bed;

• caffeine, alcohol and other substance use;

• medication timing;

• snoring, gasping or breathing pauses;

• restless legs symptoms; and

• the difference between daytime fatigue and sleepiness.

Insomnia and sleep apnoea can occur together. Treating one does not necessarily resolve the other, so suspected sleep apnoea, restless legs syndrome or another sleep disorder may require separate assessment.[8]

2. Cognitive behavioural therapy for insomnia

Cognitive behavioural therapy for insomnia, usually called CBT-I, is the recommended first-line treatment for chronic insomnia. It is a structured treatment rather than a collection of general sleep tips.

CBT-I usually includes:

• Stimulus control: rebuilding a strong association between bed and sleep.

• Careful adjustment of time in bed: matching time in bed more closely to actual sleep while gradually improving sleep efficiency.

• Cognitive strategies: addressing unhelpful beliefs, fear and excessive monitoring of sleep.

• Relaxation and arousal-reduction strategies.

• Education about sleep regulation and supportive sleep habits.

Sleep hygiene may support these strategies, but sleep hygiene alone is generally not considered an adequate treatment for established chronic insomnia.[5,8]

A meta-analysis of CBT-I trials in people with chronic pain found substantial average improvements in sleep, with smaller improvements in pain and depressive symptoms. Sleep benefits remained evident at follow-up, whereas pain benefits were more modest.[6] A later randomised trial in people with chronic spinal pain found that adding CBT-I to pain management improved insomnia severity and sleep quality but did not improve pain intensity more than pain management alone.[7]

A realistic expectation is therefore that CBT-I will primarily treat insomnia. Better sleep may also help mood, function and pain interference, and may modestly reduce pain for some people, but meaningful pain relief is not guaranteed.[6,7]

3. Use sleep-supportive habits without turning sleep into a performance test

Helpful foundations may include:

• Maintaining a reasonably consistent waking time, including after a poor night.

• Going to bed when sleepy rather than forcing sleep at a prescribed early time.

• Obtaining daylight, particularly in the morning, to help regulate the body clock.

• Maintaining tolerable daytime movement and activity, adjusted to the person’s health and functional capacity.

• Developing a predictable, low-stimulation wind-down routine.

• Reducing bright light and emotionally stimulating content near bedtime when these delay sleep.

• Limiting caffeine later in the day according to individual sensitivity.

• Recognising that alcohol may produce initial drowsiness but can fragment later sleep and worsen snoring or sleep-disordered breathing.

• Using naps purposefully; long or late naps may interfere with night-time sleep, although planned daytime rest may remain appropriate for some people.

These behaviours are best treated as flexible supports rather than rigid rules. Excessive monitoring and striving for “perfect” sleep can itself increase arousal and make insomnia more persistent.[5,8]

4. Integrate sleep care with pain management

Sleep treatment is not a substitute for assessing and treating the pain condition. It is usually most useful when integrated with an individualised pain-management plan, which may include:

• pacing activities across the day;

• gradual and appropriately prescribed physical activity;

• physiotherapy or exercise-based rehabilitation where indicated;

• comfortable positioning and practical bedtime strategies;

• relaxation or arousal-management skills;

• psychological treatment for depression, anxiety or trauma-related symptoms;

• a plan for responding to pain flares; and

• review of medicines and their timing.

The goal is not necessarily perfect sleep or complete pain relief. A more useful aim may be more predictable sleep, less time awake and distressed in bed, greater daytime alertness and improved ability to participate in meaningful activities.

5. Use medication cautiously and for a clear indication

Medication may be appropriate for selected people, but there is no single medicine that reliably treats both chronic pain and chronic insomnia. A medicine that feels sedating does not necessarily improve restorative sleep, next-day functioning or breathing during sleep.

Medication review should consider the intended indication, expected benefit, duration of use, interactions, next-day impairment and the possibility of tolerance or dependence. Particular care is needed when several sedating medicines are used together.

Chronic opioid therapy can alter sleep architecture and is associated with sleep-related hypoventilation, central sleep apnoea and obstructive sleep apnoea. People taking opioids who snore, wake gasping or experience marked daytime sleepiness may require assessment for sleep-disordered breathing.[9] Medicines should not be started, stopped or changed abruptly without advice from the relevant prescriber.

When to seek further assessment

Consider discussing sleep with a general practitioner or appropriately qualified sleep clinician when:

• sleep difficulties have persisted for approximately three months or longer and are affecting daytime functioning;

• there is loud habitual snoring, gasping, choking or witnessed pauses in breathing;

• there is significant daytime sleepiness or drowsiness while driving;

• uncomfortable leg sensations or an urge to move the legs repeatedly interfere with sleep;

• nightmares, unusual movements or behaviours occur during sleep;

• several sedating medicines, opioids or sleeping tablets are being used;

• mood, anxiety or trauma-related symptoms are substantially affecting sleep; or

• basic sleep strategies have not helped.

A person should not drive or operate dangerous equipment when excessively sleepy.

The key message

Sleep is not merely a passive casualty of chronic pain. It can influence pain sensitivity, mood, energy, concentration and daily function, and persistent sleep disturbance deserves assessment as a clinical problem in its own right.

For chronic insomnia, CBT-I has the strongest evidence and is recommended as first-line treatment. Its effects are generally larger and more reliable for sleep than for pain. Nevertheless, better sleep can still make pain management, rehabilitation and everyday life more manageable.

Addressing sleep may weaken one reinforcing part of the pain–sleep cycle. It should be considered one component of person-centred, multidisciplinary pain care—not a promise of cure.[1,5–8]

General information disclaimer

This article provides general educational information and is not a substitute for individual medical assessment, diagnosis or treatment. It does not recommend any specific investigation, medicine, procedure or other therapy. Treatment suitability varies according to the diagnosis, medical history, other medications and individual circumstances. Concerns about persistent pain and/or sleep problems should be discussed with an appropriately qualified health practitioner.

Last medically reviewed: 15/08/2026

REFERENCES

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7. Malfliet A, De Baets L, Bilterys T, et al. Cognitive Behavioral Therapy for Insomnia in Pain Management for Nonspecific Chronic Spinal Pain: a randomized clinical trial. JAMA Network Open. 2024;7(8):e2425856. doi:10.1001/jamanetworkopen.2024.25856.

8. Sweetman A, Andronis C, Hancock K, Stocks N, Lack L, McEvoy RD. General practitioner assessment and management of insomnia in adults. Australian Journal of General Practice. 2023;52(10):691–698.

9. Rosen IM, Aurora RN, Kirsch DB, et al. Chronic opioid therapy and sleep: an American Academy of Sleep Medicine position statement. Journal of Clinical Sleep Medicine. 2019;15(11):1671–1673. doi:10.5664/jcsm.8062.