Chronic pain often fluctuates during the day and for some it worsens at night — but why?

As many as one in five adults in the US — 50.2 million — experience chronic pain, according to a recent survey. These people usually encounter fluctuations in pain during the day: sometimes it’s better in the morning and worse in the afternoon, or the opposite.

But what happens when the sun sets? Some research — supported by many chronic pain sufferers — suggests chronic pain worsens at night.

“The end of the day doesn’t mean people necessarily get a break from flare-ups,” says Ellen Slawsby, director of pain services at Harvard-affiliated Benson-Henry Institute for Mind Body Medicine. “In some cases, nighttime is when pain is the worst and can drastically interfere with sleep.”

What is chronic pain?

Chronic pain is defined as pain that lasts at least two to three months, often long after a person has recovered from the original injury or illness. The pain may even become a permanent issue. It can strike individual joints or muscles, or affect only certain areas of the body like the back and neck. Persistent pain may be more diffuse from conditions such as arthritis or fibromyalgia.

Symptoms and severity of chronic pain vary and can include a dull ache; shooting, burning, stabbing, or electric shock–like pain; and sensations of tingling and numbness.

Why might chronic pain increase at night?

There are several reasons why pain might worsen at night. Hormones could be a major factor, says Slawsby. “Nighttime is when the production of the anti-inflammatory hormone cortisol is at its lowest.”

New research also has suggested that pain may follow a circadian rhythm like the body’s internal 24-clock that regulates our sleep-wake cycle. “This helps explain why some people regularly have higher pain levels at certain times, such as during the night,” says Slawsby.

While there is no good time for chronic pain, nighttime is especially problematic, as it disrupts sleep. Insufficient sleep affects our ability to manage pain. And sleep problems are common among people with chronic pain. At least 50% of people with insomnia (the most commonly diagnosed sleep disorder) suffer from chronic pain.

“Insomnia can lead to sleep deprivation, which increases the release of proteins called cytokines that are involved in the body’s inflammatory response and makes people even more sensitive to pain,” says Slawsby.

Ways to get the rest you need if pain at night is a problem

If pain at night has been keeping you awake, trying these strategies may help you sleep better.

• Do a pre-bedtime relaxation routine. A soothing transition from a hectic day can help prepare your body and mind for sleep. “Spend at least 20 minutes before bedtime focused on relaxation, which helps slow the heart and breathing rate, decrease cortisol levels, and lower the chance of flare-ups occurring,” says Slawsby. For example:
  • take a warm or cool shower
  • perform a series of gentle stretches or yoga poses
  • do several minutes of deep breathing exercises.
• Create a healthy sleep environment. Make your bedroom as dark as possible and keep it cool (the ideal temperature is 65º Fahrenheit). Consider a sound machine that plays relaxing white noise or nature sounds. “Also, use comfortable pillows and supports for areas that have pain, like under your knees if you have back pain,” says Slawsby. Consistent routines and tools like cognitive behavioral therapy for insomnia can also help improve your sleep.
• Reframe your thoughts. People with chronic pain often worry about when their pain will occur, which can further increase stress and anxiety. “If you fear not falling asleep because of your pain, remind yourself that you’ve slept well in the past and can do so again,” says Slawsby. “If chronic pain does strike at night, remind yourself that it will go away soon, just as before. It’s difficult to change this mindset, but engaging in more positive thinking is important in mitigating pain.”

If pain wakes you up, allow your body time to recover so you can fall back to sleep. Listen to soft music or read, though preferably not on blue light–emitting electronic devices (computers, tablets, and smartphones) that affect sleep cycles. Another option is to count your breaths. Close your eyes and do a simple breathing exercise where you inhale while mentally counting to one, exhale while counting to two, and continue this pattern until you reach 10. Repeat as necessary. This can move your focus away from the pain and help relax the body. “Most of the time, you will fall back to sleep after a short while,” says Slawsby.

About the Author

Matthew Solan, Executive Editor, Harvard Men's Health Watch

Matthew Solan is the executive editor of Harvard Men’s Health Watch. He previously served as executive editor for UCLA Health’s Healthy Years and as a contributor to Duke Medicine’s Health News and Weill Cornell Medical College’s … See Full Bio View all posts by Matthew Solan