Fibromyalgia and sleep dysfunction go hand in hand. Some researchers believe that fibromyalgia is, in essence, a sleep disorder but whether it is or not it definitely is an important component to the syndrome as a whole. Lack of sleep leads to physical and mental fatigue which increasing the brain fog associated with fibromyalgia. Non-restorative sleep has also been shown to increase the tender point pain found in fibromyalgia.
“More than 90% of patients with FMS, most of whom are women, describe poor quality of sleep. Irrespective of its duration, the sleep is often perceived to be light and unrefreshing. The patient may be aware of restlessness with kicking and involuntary leg movements, or may have a sleep-related breathing disorder such as loud snoring and interruptions to breathing. On the rare occasion that sleep is restful, there is substantial improvement in daytime symptoms. Indeed, unrefreshing or nonrestorative sleep are correlated to the myalgia and tender points in FMS.” CNS Spectrums 2008
Regular sleep and FM sleep
Typically a person cycles every ninety minutes from light stage one sleep (alpha) into deeper stage two (beta) and stage three (gamma) until they reach stage four (delta) sleep. Delta sleep is the most refreshing and restorative of the stages whereas alpha is also known as REM (rapid eye movement) sleep where we do most of our dreaming. People with FM have been shown to have disrupted stage four sleep. This means while they can sleep for eight or ten hours they still wake up feeling tired because the sleep is not restorative since stage four sleep is where energy is recovered and muscles are repaired. It can also cause the level of growth hormone in the body to be low as growth hormone is primarily distributed during stage four sleep (80% comes from delta sleep). Lower levels of growth hormone leads to more muscle pain and degeneration. Lack of stage four sleep also causes cognitive impairment or brain fog as well as fatigue and muscle aches. Some people with FM also have low levels of a hormone called cortisol during the day causing fatigue and high levels at night causing insomnia. Cortisol is generally released during REM sleep but can be during any stage of sleep and its peak production is early in the morning prior to waking.
Additional sleep dysfunctions with fibromyalgia
Other than the dysfunction in the actual sleep stages with fibromyalgia, there can be additional sleep concerns. One problem that develops is simply a pain issue. Because of muscle aches and discomfort, it can be difficult to get comfortable enough to fall asleep which leads to insomnia. It can also cause frequent waking since if you are not in deep sleep and your position becomes uncomfortable or painful that can often be enough to wake you up in order for you to adjust your position.
Another issue has to do with dysfunction in the automatic nervous system. It has been recently suggested that with FM the sympathetic part of the automatic nervous system which essentially controls our fight or flight responses is perpetually stuck ‘on’. This prevents the body being able to really relax in order to sleep deeply. It ensures a person with FM is a very light sleeper, essentially still on alert. This aspect may explain why people with FM frequently wake up during the night and when they do they have difficulties falling back to sleep again.
Good sleep hygiene
The first step to address sleeping issues is to look at your sleep hygiene. While most sleep dysfunction can be complex and difficult to manage, if you maintain good sleep hygiene it will help with the treatment along the road.
• Avoid stimulants such as caffeine up to four hours prior to bedtime. Caffeine builds up in the body through the day so it is best to avoid after lunch.
• Maintain a consistent sleep pattern of waking up and going to bed at the same time.
• Avoid late night snacks. If you do snack stick to small snacks that have a lot of carbohydrates in them as these tend to aid in making you feel drowsy.
• Never exercise before bedtime but try to exercise regularly even if that exercise is going for short walks, yoga or doing some stretches.
• Have no distractions in the bedroom. No TV, video games, iPhone or laptops. Do not do your work in the bedroom. Or snack. The bedroom should be reserved for sleeping or sex and we don’t want our brain to be associating the space with other waking activities.
• Make the room as comfortable as possible for sleep. Use blackout curtains to reduce light or a sleep mask. Use some method to reduce background noise whether that is earplugs, meditation music or a white noise machine. Ensure the room is not too hot or too cold.
• Do not take frequent naps but if you feel that you need to keep them under an hour.
• Do not watch TV at least an hour before bed because it is stimulating for the brain and makes it difficult to relax. The same can likely be said for being on the computer.
Nonprescription sleep aids
There are many nonprescription herbal remedies in pill form, teas or drops. One thing you must always remember is that all of these, just like prescription medications, can have side effects and interactions. They can interact with your existing medications; for example, valerian is suggested to have the potential to increase the effectiveness of antiseizure medications, so if you take antiseizure medications this would not be the sleep remedy for you. Therefore, it is vital we consider these alternative herbal treatments just like we would any other medication and ensure we mention to our doctor and pharmacist that we are taking them.
Prescription sleep aids
Antidepressants: antidepressants are used for FM because they help with pain and increase serotonin which has been shown to be low with FM. Low doses of certain antidepressants are often used to aid with sleep. Common ones for FM are Trazodone and Elavil.
Hypnotics: Drugs such as Lunesta, Ambien, Restoril, Imovane, and Sonata. These are sleeping pills that are generally not considered for long-term use because they are habit forming.
Lack of restorative sleep combined with the interference with certain hormones released during sleep has been shown to intensify fibromyalgia symptoms and been speculated to cause some of them as well. I haven’t heard much from that theory in some time since most theories now say FM has to do with the central nervous system and abnormal pain processing. While getting quality restorative sleep regularly will not cure the syndrome it has been shown to reduce the symptoms. Therefore treating the sleep dysfunction seen in fibromyalgia is quite important to managing the condition. Often when people refer to fibromyalgia the top three symptoms are muscle pain, fatigue and sleep dysfunction but sleep dysfunction has the unique feature of having the power to intensity both pain and fatigue and therefore ought to be considered primary in the management of the syndrome overall.