How-to guide
How to Manage Insomnia With Sleep Apnea
Quick answer: About 4 in 10 people with obstructive sleep apnea also have insomnia: trouble falling asleep, staying asleep or waking too early. Having both is called COMISA. Treating both works best: cognitive behavioral therapy for insomnia (CBT-I) improves insomnia, and may also help you use CPAP more each night, especially when it starts before CPAP. Tonight, keep the same wake-up time every day, get out of bed if you are not asleep in about 20 minutes, use the bed only for sleep, and put your CPAP back on whenever you wake. Ask us how to get CBT-I.
What is COMISA?
Comorbid insomnia and sleep apnea (COMISA) means having both insomnia and obstructive sleep apnea. Insomnia is trouble falling asleep, staying asleep or waking up too early, most nights. Sleep apnea is when breathing stops and starts during sleep. About 4 in 10 people with sleep apnea also have insomnia, so it is common.
Signs include:
- Lying awake at night, or waking often and having trouble getting back to sleep
- Loud snoring, or gasping or choking during sleep
- Feeling tired, irritable or foggy during the day
- Finding it hard to fall asleep with a CPAP mask on
Why does it matter?
Each problem can make the other worse. People with both tend to feel more tired, have more trouble with mood and concentration, and find it harder to get used to CPAP than people with only one. That is why treating only one of them often is not enough.
How is it treated?
- Treat the sleep apnea, most often with CPAP. For people who cannot use CPAP, other options include an oral appliance, nasal treatment or Inspire.
- Treat the insomnia with CBT-I. Cognitive behavioral therapy for insomnia is a short program, usually 4 to 8 sessions in person, by video or online, that changes the habits and thoughts that keep you awake. It is the recommended first treatment for long-lasting insomnia.
- Together they work best. Adding CBT-I to CPAP improves insomnia more than CPAP alone. It may also help you use CPAP more each night, especially when CBT-I starts before CPAP. If you have trouble sleeping and are about to start CPAP, ask us about starting CBT-I first or at the same time.
Ask us how to get CBT-I.
What can I do tonight?
- Same wake-up time every day, weekends included, even after a bad night.
- Go to bed only when you feel sleepy, not just because it is bedtime.
- If you are not asleep in about 20 minutes, or you are awake in the night, get up and do something calm in dim light. Go back to bed when you feel sleepy.
- Use the bed only for sleep and sex, not for watching TV, scrolling or worrying.
- Limit naps. If you nap, keep it under 30 minutes and before mid-afternoon, with your CPAP on.
- Caffeine and alcohol: no caffeine after noon, and no alcohol in the 3 hours before bed; alcohol also makes sleep apnea worse.
- Screens off about an hour before bed.
- Wear CPAP all night. If you wake up, put it back on before you try to fall asleep again.
These habits help, but on their own they are usually not enough for long-lasting insomnia; CBT-I works best.
What about sleeping pills?
Talk with us before taking sleeping pills, sleep aids with diphenhydramine (such as Benadryl or Tylenol PM), or alcohol to help you sleep. Some of these relax the throat and breathing and can make sleep apnea worse, or leave you groggy the next day.
Some parts of CBT-I, such as shortening the time you spend in bed, can make you sleepier at first. Do them with a trained clinician, and do not drive if you feel drowsy.
When should I call?
Call us for
- You still have trouble sleeping most nights after a few weeks of these steps
- You cannot use CPAP most nights because you cannot fall or stay asleep with it
- You feel very sleepy during the day, or nearly fall asleep while driving. Do not drive while you feel that sleepy.
- Low mood or worry that keeps you awake
Call 911 or go to the ER for
Chest pain or trouble breathing, or thoughts of harming yourself. You can also call or text 988, the Suicide and Crisis Lifeline.
Austin 512-339-4040 · Lakeway 512-682-4798 · Marble Falls 830-992-2830
Questions patients ask
Comorbid insomnia and sleep apnea: having both insomnia and obstructive sleep apnea. About 4 in 10 people with sleep apnea also have insomnia.
Yes. People with both often find it harder to get used to CPAP. Treating the insomnia with CBT-I improves sleep and may also help you use CPAP more each night, especially when CBT-I starts before CPAP.
Cognitive behavioral therapy for insomnia: a short program, usually 4 to 8 sessions in person, by video or online, that changes the habits and thoughts that keep you awake. It is the recommended first treatment for long-lasting insomnia.
Practice wearing it while awake, get out of bed if you are not asleep in about 20 minutes, keep the same wake-up time every day, and put the mask back on whenever you wake. Ask us about CBT-I.
Talk with us first. Some sleeping pills, sleep aids with diphenhydramine and alcohol relax the throat and breathing and can make sleep apnea worse.
This guide is for educational purposes only and does not replace an in-person evaluation. If we gave you different instructions, follow ours.
Full guide: capitalent.com/insomnia-and-sleep-apnea.html
Sources
- Zhang Y, Ren R, Lei F, et al. Worldwide and regional prevalence rates of co-occurrence of insomnia and insomnia symptoms with obstructive sleep apnea: a systematic review and meta-analysis. Sleep Med Rev. 2019. PubMed
- Sweetman A, Lack L, McEvoy RD, et al. Bi-directional relationships between co-morbid insomnia and sleep apnea (COMISA). Sleep Med Rev. 2021. PubMed
- Sweetman A, Lack L, Catcheside PG, et al. Cognitive and behavioral therapy for insomnia increases the use of continuous positive airway pressure therapy in obstructive sleep apnea participants with comorbid insomnia: a randomized clinical trial. Sleep. 2019. PubMed
- Ong JC, Crawford MR, Dawson SC, et al. A randomized controlled trial of CBT-I and PAP for obstructive sleep apnea and comorbid insomnia: main outcomes from the MATRICS study. Sleep. 2020. PubMed
- Alessi CA, Fung CH, Dzierzewski JM, et al. Randomized controlled trial of an integrated approach to treating insomnia and improving the use of positive airway pressure therapy in veterans with comorbid insomnia disorder and obstructive sleep apnea. Sleep. 2021. PubMed
- Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021. PubMed
- Mysliwiec V, Martin JL, Ulmer CS, et al. The management of chronic insomnia disorder and obstructive sleep apnea: synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines. Ann Intern Med. 2020. PubMed