Neuropathic pain is common in the general population. Numerous conditions affect nerves and may present with neuropathic pain.
- Trigeminal neuralgia
- Post-herpetic neuralgia
- Diabetic neuropathies
- Multiple Sclerosis
- Post chemotherapy
- HIV infection
- Phantom limb pain
- Atypical facial pain
Neuropathic pain can present as a cramping, burning, shooting, throbbing, aching sensations or with an electric shock-like pain. Because of increased neurological sensitivity, this pain can be constant or induced by even the slightest touch or movement.
Related to the neuropathic pain:
- The pain comes or worsens with a touch or stimulus, which would not normally cause pain.
- Severe pain from a stimulus or touch that would normally cause only slight discomfort.
- Unpleasant or painful feelings even when there is no stimulus, including pins and needles or shock-like sensations.
Insomnia affects up to 50% of the general population, taking many forms: waking up too early in the morning, difficulty falling asleep, frequently waking up at night and poor sleep quality. This again can lead to many day-time symptoms including sleepiness, fatigue, depressed mood, lack of energy, cognitive impairment with memory fallout, decreased alertness and poor concentration, with irritability.
Over time this affects family life, relationships and work performance, as well as overall health and wellbeing. Sleep is thus an essential part of living. It helps us avoid major health problems and it is detrimental to our mental and physical performance.
Both neuropathic pain and sleep disturbances alone can make a person susceptible to a depressed mood, anxiety disorders, and changes in eating habits, decreased physical activity and an overall decline in health. Combine these two conditions and this can be a disaster.
According to the Journal of Pain Medicine, about 70% of people with chronic pain may have problems sleeping, compared with only 10-20% of the general population. The next logical question is then to ask how neuropathic pain will affect sleep. It can do so in many ways:
- The neuropathic symptoms can cause sleep disturbances because the pain or hypersensitivity makes it difficult to fall asleep.
- Furthermore, there is less distraction at night, making you more aware of the pain.
- The poor quality of sleep with sleep deprivation can lower your pain threshold and tolerance, worsening the experience of the pain. When you do not sleep well at night, it can make you more sensitive to the pain the following day, again leading to problems falling asleep and staying asleep.
- Anxiety, worry and depression can keep the patient awake, tossing and turning at night.
- Use of medication such as codeine disturbs sleep. Then follows the even more important question: Is there an answer?
It is crucial to understand that the treatment of neuropathic pain with sleep disturbance is to address both conditions head on and to pursue effective pain management. Numerous rating scales are available to measure both sleep and pain. The Brief Pain Inventory (BPI) may be valuable.
This measures and tracks pain severity as well as the interference of pain on seven items relating to daily functioning. The sleep interference score rates sleep disturbance from 0 to 10. The Epworth Sleepiness Scale is also useful, ranging from 0 (would never dose or sleep), to 3 (high chance of dozing or sleeping).
There are several things you can do to improve your sleep.
The following is advised for patients, helping them to fall asleep more quickly, sleep more deeply, stay asleep, and ultimately help keep healthy and improve chronic neuropathic pain:
- Keep a regular sleep/wake schedule, no matter when you fell asleep the night before.
- Develop a bedtime ritual (take a warm bath, a cup of tea, read a few pages).
- Limit or eliminate caffeine intake.
- Avoid smoking, also when waking up in the middle of the night.
- Avoid alcohol and heavy meals before going to bed.
- Avoid technology (at least for a little while), this includes TV, smartphone, computer, IPad.
- Adopt relaxation techniques to induce sleep; unwind, meditate, take deep breaths.
- Create a comfortable sleeping environment including a dark, quiet ventilated room, elevate sheets as to not touch your legs and feet if this causes pain.
- If you can’t sleep; get up and leave your room until you feel tired.
- Exercise in the morning or afternoon, not in the evening.
- Limit naps to less than one hour.
- Do not watch the clock.
- Keep a notepad and pen by your bed to write down any thoughts that may wake you up at night so you can put them to rest.
Warn patients that their sleep might initially worsen when implementing the above, and that it can take up to four weeks before seeing an improvement. Other non-pharmacological treatments include cognitive behavioural therapy, relaxation techniques, stress management and acupuncture. There are numerous pharmacological options available:
Painkillers are not always the best option. These drugs can prevent a patient from going into REM sleep. One of the biggest culprits are strong opioid drugs. In one study it was found that only Acetaminophen can help relieve pain without increasing the likelihood of disturbing a person’s sleep at night.
There are other drugs that may help. Benzodiazepines are used to help people struggling to fall asleep and staying asleep. There are also the non-benzodiazepine sleeping tablets. These drugs should however be used with caution and not for prolonged periods of time.
A better choice is perhaps the use of anti-depressants (tricyclic and SNRI drugs) or anti-seizure medication (gabapentin or pregabalin), which can help with the management of the pain and improve sleep.
Sometimes combinations of therapies are needed to improve pain management. Since these drugs work on different mechanisms, they may complement each other or even have an additive effect on easing the pain.
Lidocaine gel and capsaicin cream (only available overseas) applied to the skin, can bring relief if applied frequently.
The aim is most certainly to find the lowest dose required to ease the pain, which will lower the side effect profile.
It is said that desperate times calls for desperate measures. When desperate, this may even bring the potato in bed with you to relieve chronic neuropathic pain. It is important to remember that management of neuropathic pain is essential, but must be seen in the context of where and when the patient experiences the worst pain. When managing these patients, a good night’s sleep is not a luxury; it is vital for a good quality of life.
DPNP and Impairment of Sleep: exploring the complex relationship. Fishbain DA. Pain medicine news. Dec 2007:18-19\
Insomnia: Prevalence, Impact, Pathogenesis, Differential Diagnosis and Evaluation. Mai E, Buysse DJ. Sleep Med CLin. 2008:3(2): 167-174
Peripheral neuropathy fact sheet: National Institute of Neurological Disorder and Stroke. NIH Publication number 15-4853