As the fourth most common neurological disorder, epilepsy affects 3 million Americans. Epilepsy starts in the brain, the same part of your body that regulates your sleep.
In addition to recurring seizures, people with epilepsy also experience sleep issues that further disrupt their daily lives, including nocturnal seizures, insomnia, sleep apnea, and daytime fatigue.
Keep reading to learn more about the connection between epilepsy and sleep, the common sleep problems affecting people with epilepsy, and how to get better sleep and mitigate seizures.
Recurring seizures are a hallmark symptom of epilepsy, but a person can have seizures without being epileptic. While just over 1% of Americans have epilepsy, up to 10% of people will experience a seizure at some point during their lives.
What is a seizure? Technically, a seizure is defined by a sudden change in behavior due to increased electrical activity in the brain. People may become unconscious, shake violently, or stare. The seizure usually lasts for only a couple of minutes. The physical symptoms of a seizure may vary, but it all stems from the brain. Seizures are disruptive and potentially dangerous to the person experiencing one, depending on when they occur and what the person is doing at the time.
To be diagnosed with epilepsy, a person must experience two unprovoked seizures at least 24 hours apart that were not caused by another, explainable trigger such as very low blood sugar. Besides epilepsy, seizures can also be caused by:
- Head and brain injuries or infections, tumors or strokes
- Substance abuse or withdrawal
- Alcohol withdrawal
- Extremely low blood sugar
Epilepsy can develop at any point in a person’s life, but it is most commonly diagnosed before age 10 and after age 55. Unfortunately, doctors don’t know what causes epilepsy or associated seizures, although they have observed it can run in families. People with epilepsy are also at increased risk for migraines, depression and anxiety disorders, and obesity.
Your brain regulates your sleep-wake cycle, when you get tired and when you fall asleep, and how much time you spend in each stage of sleep. The electrical charges that develop into seizures also begin in the brain. Since both seizures and sleep occur in the brain, it makes sense that they would be connected.
Sleep problems and epilepsy share a complex relationship where each impacts the other. One study summarized it thusly:
- Electrical brain activity during light sleep may spur seizures.
- Daytime seizures and antiepileptic drugs (AEDs) like anticonvulsant can contribute to fragmented sleep and reduced sleep efficiency.
- Comorbid sleep disorders further disrupt sleep, exacerbate symptoms of epilepsy, and impair overall quality of life.
- Some symptoms of the sleep disorders themselves mimic seizures, which can prevent individuals from receiving a proper diagnosis and effective treatment afterwards.
The most common sleep problems affecting individuals with epilepsy include nocturnal seizures and insomnia, sleep deprivation and daytime fatigue, and sleep apnea.
Nocturnal seizures and insomnia
Some people experience seizures only during sleep, known as nocturnal seizures or sleep-related epilepsy. Between 7.5 to 45% of people with epilepsy experience these sleep seizures. They’re most common during child, affecting up to 60% of children with epilepsy.
Since they’re asleep when the seizure occurs, it’s not uncommon for people to not realize that what’s waking them up is actually a seizure – and then mistakenly self-diagnose with insomnia. As a result, their problem will persist since they never get treatment for the root issue: night seizures.
Signs you experienced a nocturnal seizure include waking up confused, feeling pain from biting your tongue or grinding your teeth, or discovering you were incontinent. Others, like a sleeping partner or parent, may observe you making involuntary movements.
However, these symptoms can also stem from another sleep disorder like sleep bruxism or periodic limb movement disorder, which is why it’s important to get properly diagnosed. Your doctor may recommend an overnight sleep test in a laboratory, called a polysomnogram, where sleep technicians will monitor your brainwaves and more to detect nocturnal seizures.
Nocturnal seizures typically occur in stage 1 or 2 of light sleep, thus interrupting sleep and preventing the individual from reaching slow-wave and REM sleep. The end result is overall reduced sleep efficiency.
People with epilepsy have poorer sleep efficiency than the general population, but the effect is heightened when they have nocturnal seizures (indicated by NTSZ in the chart below). The study behind this chart found that even when one experiences seizures during the day, it can worsen sleep the following night.
A nocturnal seizure interrupts a person’s sleep cycle by waking them up. As a result, they may spend a shorter amount of time asleep each night than is ideal.
Plus, each time they fall back asleep, their sleep cycle begins anew, so they don’t get enough deep and REM sleep, which are concentrated in the letter half of the night. Both of these stages are critical for muscle repair and recovery, memory consolidation, and more essential functions.
When we don’t get enough sleep, we become sleep deprived. We’re more on edge during the day, less able to focus, and in the long run it compromises our immune system to the extent that we’re at risk for cardiovascular disease and hypertension.
Problematically, sleep deprivation itself can trigger seizures. Sleep deprivation, along with emotional stress and tiredness (two effects of sleep deprivation) are the top three triggers for seizures, according to one large study from Norway.
Researchers estimate one-third of people with epilepsy have undiagnosed sleep apnea, according to one University of Michigan study. They’ve also observed a link between sleep apnea and the likelihood of experiencing nocturnal seizures.
Obesity is another risk factor for sleep apnea, and weight gain is a side effect of many AEDs individuals take to manage their seizures.
Obstructive sleep apnea (OSA) occurs when there is a narrowing of the airways, resulting in suspended breathing during sleep and lower levels of oxygen in the blood. OSA can cause sleep-deprivation, which in turn can aggravate seizures. OSA is a treatable condition, but if people are not aware they have it, their sleep problems will continue.
One 2008 study sought out to see whether CPAP treatment could be effective for people with epilepsy. The lower line in the graph below, shows that after using CPAP, individuals indeed experienced a significant reduction in apneic episodes.
As they age, older adults are at increased risk of developing OSA. Unfortunately, for older adults with epilepsy, they’re also more prone to experience more disruptive seizures. Researchers from a 2007 study confirmed that OSA is linked with seizure exacerbation for older adults with epilepsy, and recommended treating the underlying OSA to improve seizure control.
All of the sleep problems described above result in daytime fatigue. Fatigue interferes with quality of life. This may explain the results of one study of patients with partial epilepsy. The researchers found people with partial epilepsy are twice as likely to experience disturbed sleep, and they experience poorer quality of life as a result.
Fatigue is common independently in both epilepsy and depression, and people with epilepsy are at increased risk for both fatigue and associated depression. Fatigue can also be a side effect of AEDs. Between 44 to 50% of people with epilepsy experience fatigue.
However, often times the cause behind excessive daytime sleepiness in people with epilepsy is an undiagnosed sleep disorder, which can be improved by treating that sleep disorder.
Children and epilepsy
For children with epilepsy, these consequences from sleep problems are much more dire. Children who experience insomnia or sleep deprivation due to their seizures are much likelier to have difficulty focusing in school, display social or behavioral problems, experience impaired cognitive development, and have an increased risk for attention-deficit/hyperactivity disorder (ADHD).
When children with epilepsy can’t sleep, neither can their parents. According to one study, parents of children with epilepsy only get 4 hours of sleep per night (which is way lower the recommended minimum of 7 hours for adults), and experience higher levels of stress and decreased marital satisfaction.
Sleeping well on a regular basis is important for everyone, but it’s especially important for anyone with epilepsy hoping to reduce the number and frequency of seizures they experience.
1. Get regular sleep.
Follow a regular bedtime and wake-up time, and set aside enough time for you to realistically get 7 hours of sleep.
If your child has epilepsy, they need even more sleep, depending on their age. Check how much sleep is recommended for your child here.
Try not to nap too frequently, as this will only make it tougher to fall asleep at night. If you are excessively fatigued, limit it to a single power nap of 30 minutes or less.
2. Exercise and eat well.
Caffeine and alcohol both interfere with sleep. One makes it difficult to fall asleep (caffeine), while the other wakes you up too early (alcohol). Avoid these in large doses, especially in the evening.
Eating too much at night, especially if it’s overly sugary or fatty, can also make it tough to fall asleep.
3. Review your medication.
Speak with your doctor to rule out any anti-seizure medication you’re taking as the cause of your sleep problems. If sleep issues are a common side effect, see if there’s an alternative medication you can switch to, or if there’s a way you can adjust your dosing schedule to improve sleep.
4. Reduce pre-sleep stress with a calming bedtime routine.
Stress is a trigger for seizures, so create a routine that relaxes your mind and body before bed.
Take a warm shower or bath – as your body cools down, so will your mind, signaling to your brain that it’s time to sleep. Try aromatherapy (but double-check with your doctor first to ensure the essential oils won’t interfere with your medication). Practice meditation, deep breathing, or progressive muscle relaxation exercises. Stop using electronics and checking your phone or email.
The idea is to follow the same set of activities each night to train your brain into recognizing it’s bedtime.
5. Make your bedroom safe and comfortable to avoid injury.
Invest in a padded headboard. Get floor mats and pads to surround your bed, and get a low base for your bed in case you fall out during a night seizure. Remove sharp furniture or fragile objects from around the bed.
All of these precautions will help you rest assured (pun intended) that if you do have a seizure, you won’t get hurt, which may relieve some anxiety around falling asleep in the first place.
6. Treat your sleep apnea.
If you’re concerned you have sleep apnea, speak to your doctor. There are many ways to treat sleep apnea.
CPAP therapy has shown to be effective for individuals with comorbid epilepsy, as can more serious approaches such as a tracheostomy or another surgery. One study of obese pediatric patients found that sleep apnea surgery decreased frequency of seizures or eliminated them altogether (a happy outcome that occured in one-third of patients).
While consistent CPAP therapy is the best way to reduce symptoms of sleep apnea, it can be uncomfortable. A less invasive, although less effective approach, is a mandibular advancement device. This is an appliance molded to your teeth that pushes your tongue forward while you sleep, freeing any obstruction from your throat.
Behavioral approaches to treating sleep apnea include changing from sleeping on your back to your side, and losing weight if you’re obese.