Sleep Disorders in Multiple Sclerosis: Causes and Treatment Options

The alarm clock rings and it feels as if the sharp sound is brutally sawing its way through the middle of your brain. No wonder if you lie awake for hours at night, brooding or tossing and turning for other reasons. Many MS patients experience sleep disorders to a greater or lesser extent. A good half of those affected do not feel sufficiently rested in the morning - and everyone knows that poor sleep can really wear you out. What's more, lack of sleep costs you quality of life and can trigger or worsen symptoms such as fatigue .

When does it become a sleep disorder?

How much sleep you need depends on many individual factors. That's why it's not how long you sleep that matters, but how refreshed you feel after sleeping. Sleeping more is not necessarily the solution, because too much sleep can actually make chronic fatigue worse. The causes of sleep disorders are complex, as are the symptoms: Is it a problem falling asleep or sleeping through the night? Is the problem the amount of sleep or the quality of sleep? In the following sections, we have compiled the most common causes, symptoms and solutions for sleep disorders in MS patients. The most commonly diagnosed form of sleep disorder in multiple sclerosis, however, is so-called primary insomnia. This is not a direct consequence of MS, because about the same number of people who do not have a chronic illness suffer from it. It is therefore not based on any identifiable illness - and therefore has nothing to do with the MS diagnosis.

Sleep disorders as a symptom of multiple sclerosis

The German Society of Neurology states in its guideline document "Isomnia in neurological diseases" that between 25 and 55 percent of patients with multiple sclerosis suffer from sleep disorders. Sleep medicine specialists distinguish between around 80 different types of sleep disorders, but only two are directly linked to the relapses of multiple sclerosis, and they are also very rare: narcolepsy and REM sleep behavior disorder. If these types only appear with the MS disease, this can, under certain circumstances, be seen as an indicator of the need for relapse therapy. The reason: In both cases, researchers suspect that lesions in the central nervous system could be involved in the development. Those affected can gain clarity about this by being examined by a neurologist, who can then also suggest a suitable treatment concept.

Therapy as a cause of sleep disorders in multiple sclerosis?

Sleep disorders can often occur, especially in the context of corticosteroid therapy, as the hormone can affect melatonin levels. In a smaller study, researchers were able to demonstrate in an animal model that the melatonin serum level is reduced immediately after steroid pulse therapy. This low melatonin level is a possible cause of sleep disorders, as the hormone has an important influence on the regulation of the human wake-sleep rhythm. Food supplements containing the body's own messenger substance can therefore provide relief. Melatonin helps to shorten the time it takes to fall asleep. This is confirmed by the recommendations of the European Food Safety Authority, which states: The positive effect occurs when 1 milligram of melatonin is taken shortly before going to bed. In a control study with 102 MS patients, a positive effect of 5 mg of melatonin on previously existing insomnia was even found. Before taking such products, affected individuals should consult a doctor to discuss whether melatonin should be used as a possible treatment option.

Pain and spasticity: How should you sleep with it?

All illnesses that are associated with pain disrupt sleep at night. Pain not only prevents those affected from falling asleep, it also wakes them up at night or prevents them from having a deep, restful sleep. In MS patients, pain can occur primarily in connection with spasticity, i.e. muscle cramps and increased muscle tension. But pain can also occur when nerve fibers that transmit pain impulses are damaged or unusually excited. In order to find a solution for severe and frequent pain, a doctor must first determine the exact causes. Whole libraries can be filled with the individual treatment options for this type of pain; they range from antispasmodics to targeted exercise therapies or diets to conventional painkillers.

Depression as a cause of sleep disorders: When are medications useful?

Depression is a common comorbidity in people with multiple sclerosis. But even less severe psychological stress can rob you of sleep - after all, the diagnosis of MS has a significant impact on the lives of those affected. Psychotropic drugs can help in cases of serious symptoms. If you have been feeling this kind of stress for a long time, you should discuss with your doctor whether such medications are useful for you. Doctors most commonly prescribe benzodiazepines, non-benzodiazepine hypnotics and antidepressants. However, some antidepressants are suspected of causing sleep disorders themselves - so the benefit in the case of poor sleep quality can be very limited, regardless of other undesirable side effects.

Cognitive Behavioral Therapy for Sleep Disorders: When Your Head Is Racing

Cognitive behavioral therapy for sleep disorders is a sensible alternative to psychotropic drugs (also read our general article on behavioral therapy for MS patients ). Studies show that this approach achieves good results if there are no significant physical causes for the difficulty falling asleep or staying asleep: despite the short treatment period, psychotherapy is often just as effective as drug therapy. One goal of this approach can be to work out certain behaviors in order to develop what is known as sleep hygiene. This often means simple things like incorrect sleeping times (naps) or environmental factors (too much light). Meditation or other relaxation techniques can also be used in behavioral therapy to improve control over the physical processes involved in falling asleep. Sleep restriction, which can reset the sleep-wake rhythm, can also help: by setting and sometimes shortening sleeping times and durations, those affected spend less sleep-free time in bed. Being awake for longer increases tiredness and shortens the time it takes to fall asleep. There are also cognitive techniques that are designed to help suppress thoughts that prevent sleep, because in addition to behavior and habits, certain cognitions and thought patterns also prevent falling asleep and sleeping through the night. Distracting techniques such as thought stopping can, for example, break cycles of rumination at night. However, due to the high demand, therapy places are scarce. Apps that support users in dealing with thoughts that prevent sleep or in achieving a sleep-promoting state using relaxation techniques also promise help. The “Somnio” app, for example, offers evidence-based and guideline-compliant content from the field of cognitive behavioral therapy for insomnia - and it is approved by the Federal Ministry for Drugs and Medical Devices as a benefit component of statutory health insurance.

Herbal Helpers and Home Remedies for Inner Restlessness

You don't always need medication or therapy if you feel restless or your thoughts are racing and preventing you from sleeping. Temporary and mild sleep disorders can often be remedied with home remedies - because even without scientific evidence of the effectiveness of each individual home remedy, we are doing ourselves some good. The popular hot milk with honey, for example, contains the amino acid tryptophan, which is converted into the anti-stress hormone serotonin. The proportion of the amino acid is very small, but the taste alone brings back calming memories of childhood for some people. Many plants have also been used for centuries to find the peace and quiet needed for sleep. Many people trust in the sleep-promoting or calming effect of teas with hops, valerian, lavender or lemon balm. Many of the valuable plants are also included as extracts in food supplements, often in combination with nutrients such as magnesium, biotin or vitamin B6, which in turn contribute to normal psychological function.

When the bladder presses at night

One of the most common reasons for insomnia is going to the toilet at night. In MS patients, the cause is usually neurogenic bladder disorders, in which the function of the nerve pathways that control bladder activity is damaged. This can lead to increased urge to urinate, problems emptying, and incontinence – or to complications such as kidney stone formation or urinary tract infections . If you are suffering from these symptoms, you should seek medical help: neurogenic bladder disorders require an interdisciplinary approach – the treatment plan is therefore usually drawn up in collaboration between neurologists and urologists. Numerous therapeutic approaches are available, from surgical interventions to aids such as bladder catheters and medication. If the symptoms are mild, however, you can also help yourself: if you have an overactive bladder, it is a good idea to control the amount you drink and urinate using a so-called micturition diary. At the same time, in this case, you can reduce the amount you drink by around 25 percent, provided your body still receives sufficient fluids – i.e. at least one liter. Pelvic floor exercises can help strengthen the muscles so that you have better control over emptying your bladder. In addition to the well-known home remedies, nutritional supplements with plant extracts and other ingredients are available for bladder and urinary tract infections.

Legs with a life of their own: Restless Legs Syndrome

A common symptom of multiple sclerosis as the disease progresses is restless legs syndrome (RLS). The bad thing about it is that the more those affected try to rest, the greater the urge to move their extremities. The urge to move can become downright tormenting; those affected also often feel an unpleasant pulling or tingling sensation in their legs, as if ants or snails were running over them. The causes of RLS have not yet been fully clarified, but it has been proven that MS patients suffer from it up to four times more often than the average population - up to 19 percent. Researchers suspect that damage to the spinal cord or side effects of medication are to blame for the legs acting on their own. Those affected should discuss possible treatment approaches with their neurologist. Drugs from the group of dopamine antagonists are available, for example. To help themselves, those affected should avoid alcohol and cigarettes as much as possible, as both are suspected of intensifying RLS.

Sleep medicine examination: exploring the causes of sleep deprivation

The causes of poor sleep quality are not always so easy to determine. Many sufferers lie awake at night, even without psychological problems, pain or the urge to urinate. So what is the reason? The answer can be found in a sleep medicine examination (polysomnography) in a sleep laboratory. Whether an overnight stay in such a laboratory makes sense for the individual should be clarified in a medical consultation - ideally with a specialist in sleep medicine. During the examination, numerous measurements are taken, including brain waves, eye and leg movements, oxygen levels in the blood and heart rate. In order to find other abnormalities and include them in the analysis, patients in the sleep laboratory are also monitored with an infrared video camera and a microphone. From the results, the experts can derive other causes of sleep disorders and suggest suitable therapies.

Effects of poor sleep on multiple sclerosis

Sleep disorders are not only a side effect of multiple sclerosis or the associated therapies - they are also a possible risk factor. Doctors call this a prodromal symptom: In a study of over 10,000 MS patients, several symptoms were identified that could be documented up to ten years before the onset of actual MS, including various types of intestinal or stomach disorders. Insomnia is also one of the prodromal symptoms. Sleep disorders can actually precede the MS diagnosis by up to 10 years. The authors of the study conclude that including these symptoms in the diagnostic process can even help to detect the disease earlier.

Self-test: Do I suffer from sleep disorders?

Only a doctor can reliably determine whether you have a sleep disorder. However, there are some factors you can observe in yourself to decide whether it makes sense to see a doctor. If one or more of these statements apply to you, you may have a sleep disorder:

• I often feel tired, unfocused and listless during the day, despite normal sleeping times.
• Before or when I go to bed, I worry intensely about whether I will be able to fall asleep at all.
• I regularly have trouble falling asleep several times a week in the evening and lie awake for long periods.
• I regularly take sleeping pills so that I can fall asleep and sleep through the night.
• I've been told that I often snore or have breathing pauses at night.
• When I wake up in the middle of the night, I usually can't get back to sleep.

If you find one or more of these statements to be true for you, your family doctor can help you and, if necessary, refer you to an expert.

External sources

• Insomnia in neurological diseases (AWMF – Guidelines of the German Society of Neurology)
• Sleep quality, daytime sleepiness, fatigue, and quality of life in patients with multiple sclerosis treated with interferon beta-1b: results from a prospective observational cohort study (Sylvia Kotterba et al., 2018 – English source)
• Prodromal symptoms of multiple sclerosis in primary car (Giulio Disanto et al., 2018 – English source)
• Corticosteroid therapy exacerbates the reduction of melatonin in multiple sclerosis (Shima Dokoohaki et al., 2017 – English source)
• Sleep disorders in multiple sclerosis (Christian Veauthier, 2019)