Poor sleep is common in people with multiple sclerosis, with about 50% of people with MS reported to experience some form of sleep disturbance. Despite this being well known, sleep disorders are under-diagnosed and under-treated in people with MS.
Poor sleep quality and quantity can impact on daily life, causing daytime sleepiness, decreased concentration and memory, worsening depression, and the inability to work effectively. A lack of sleep can also lead to low energy levels or make pain, fatigue, and other symptoms of MS much worse.
The types of sleep problems that you may experience include difficulty falling asleep, difficulty maintaining sleep (such as waking up during the night or not being able to fall back asleep immediately) and early wakening.
Speak to your GP or MS team if sleep problems are affecting you. There may be treatments that can help. By addressing the causes of poor sleep quality and establishing good daily sleep habits, you may find you can greatly improve your overall energy levels and quality of life.
Causes of sleep disturbance in MS
There can be many reasons why getting good quality sleep is difficult:
MS related symptoms that make sleep difficult or interrupted. These include:
- pain (neuropathic or musculoskeletal)
- restless legs syndrome
- anxiety and/or depression
- side effects of certain medications
- nocturia (the urge to urinate frequently at night)
- sleep apnoea (abnormal pauses in breathing)
- high levels of daytime fatigue.
- Family responsibilities that mean less time is available for sleep
- Concerns and worries that make it difficult to 'switch off' and drift into sleep or produce restless sleep
- Some disease modifying drugs and drugs taken to manage MS symptoms can affect sleep
- Being sedentary or less active can alter sleep patterns
- A lack of exposure to daylight during the day can affect sleep patterns
- A lesion in the region of the brain responsible for sleep can affect sleep patterns
Treatment and management
Treating sleep disorders has been shown to improve other MS symptoms, particularly cognitive function, fatigue, depression and pain. These in turn can affect disability and quality of life.
Many of the MS symptoms that can cause sleep disturbance are treatable. If you are currently not receiving treatment for them, or if the medication you are taking is affecting your sleep, do speak to your MS team. Changing your medications or altering the time you take the treatment could help. For example, treatment options for pain can include medications such as gabapentin, which has been shown to improve nocturnal pain and also promote restorative sleep.
The beta interferon DMDs, including Rebif, Avonex, Plegridy, Betaferon and Extavia, are known to affect sleep efficiency on the day treatment is taken. Usually, the advice with these drugs is to take them in the evening, so that you can sleep through the side-effects. However, some people prefer to take them in the morning, if the side-effects are manageable, as then their sleep is less affected.
On the positive side, some MS treatments have positive effects on sleep. Two studies have shown that natalizumab (Tysabri) treatment improved fatigue and sleep patterns. There is no evidence for other DMDs and their impact on sleep. Cannabis and medicinal extracts of cannabis are associated with improved sleep patterns, reduced sleep disruption and reduced depression. These effects may be directly due to the cannabinoids taken, or indirectly due to reduced spasticity and pain as a result of the treatment.
Podcast: Sleep problems in MS
In this podcast we speak to consultant neurologist Dr Kirstie Anderson, who has a special interest in sleep problems. Here she talks about which sleep disorders are more common in MS and shares her tips for getting a better night's sleep.
General tips to improve sleep quality
Coping with poor sleep, Diana writes:
I noticed that I don't seem to sleep as well as I used to pre-diagnosis. I make a point of going to bed early with a book and not eating supper or drinking caffeine too late in the evening.
Sleep quality can be improved by establishing regular habits or good 'sleep hygiene':
- try to stay as physically active as possible during the day, but allow plenty of time to wind down before bedtime
- avoid getting overtired by doing too much, as being too tired can make it difficult to get to sleep
- ensure some daily exposure to sunlight and avoid bright lights in the evening
- avoid unnecessary stress or stimulants (eg caffeine, chocolate, alcohol) in the late afternoon and evening
- keep the same nightly ritual every day throughout the week
- establish a bedtime routine that can include, for example, relaxation, a warm 'milky' drink, taking a warm bath
- only use the bed as a place for sleeping, not for other activities such as watching TV
- instead of lying in bed awake, after 15 minutes of not sleeping get out of bed and do something calming or boring, and return after a short period of time
- avoid getting too hot; although some people find having cold feet can also disturb sleep
- J Clin Sleep Medicine 2014 Sep 15: 10(9): 1025-1031 Full text The underdiagnosis of sleep disorders in patients with multiple sclerosis
- Multiple Sclerosis 2017 Jan;23(1):5-13 Summary The impact of drugs for multiple sclerosis on sleep
- Multiple Sclerosis 2006;12(4):481-486. Summary Sleep and fatigue in multiple sclerosis.
- Sleep Medicine 2014 May; 15(5):21 Summary Sleep disorders in MS and their relationship to fatigue
- Behav. Sleep Med. 2018 Mar-Apr:16 (2) 106-116 Summary Is poor sleep quality associated with greater disability in patients with multiple sclerosis?
- Journal of Neurology, Neurosurgery & Psychiatry 2012;83:1125-1132. Full report MUltiple Sclerosis and Extract of Cannabis: results of the MUSEC trial