Why arthritis symptoms get worse at night

Researchers have several theories to explain why many people with arthritis experience worse pain at night.

One theory is that the body’s circadian rhythm may play a role. In people with rheumatoid arthritis (RA), the body releases less of the anti-inflammatory chemical cortisol at night, increasing inflammation-related pain.

Other processes may also intensify RA pain, including the nighttime release of pro-inflammatory cytokines, an increased number of cells traveling to inflamed tissue, and changes in the body’s immune response.

Additionally, the body releases higher levels of melatonin and prolactin at night, both of which can cause an increase in inflammatory cytokines.

A person’s arthritis inflammation and pain may worsen if:

• they are already in pain when they go to bed
• their mattress or pillow puts pressure on their joints and irritates their arthritis
• they have other risk factors for insomnia, such as high stress levels or drinking caffeine before bed

How arthritis disrupts sleep

Many studies show a link between arthritis and sleep deprivation. People with arthritis may have trouble falling asleep and staying asleep. They may also report lower quality sleep due to the pain that the condition causes.

A 2021 study involving 133 people with arthritis and 76 matched controls found that 54.1% of people with arthritis reported poor sleep quality. The issues included:

• greater difficulty falling asleep
• shorter periods of sleep
• poor sleep quality
• more daytime problems related to poor quality sleep

A 2018 study reached a similar conclusion. The researchers compared 178 people with arthritis — 120 with RA and 58 with osteoarthritis (OA) — with 51 people with no arthritis. The rate of insomnia was comparable between the OA and control groups, at 32% and 33%, respectively. However, insomnia was significantly more prevalent among the RA group, affecting 71% of these participants.

Both studies also found a link between arthritis and mental health. People with arthritis were more likely to report marital problems and experience depression, suggesting that insomnia may be a reaction not only to arthritis but also to stress.

The link between arthritis pain and sleep goes in both directions. For example, arthritis can make it difficult to sleep, but sleep deprivation can also worsen arthritis pain. A 2018 study found that pain intensified as sleep worsened. In addition, a 2017 study found that people with knee OA who had poor quality sleep were more likely to ruminate on their pain.

Tips to get better sleep with arthritis

As insomnia can make pain worse, it is important that people with arthritis take steps to improve their sleep, as well as treating their pain.

Practice better sleep hygiene

Tossing and turning at night when unable to sleep may cause a person to notice and fixate on their pain. Good sleep hygiene may help a person fall asleep faster and remain asleep longer. People can try the following:

• going to bed at the same time each night and establishing a bedtime ritual, such as taking a bath, meditating, or doing another calming activity
• avoiding daytime naps
• exercising during the day to ease arthritis symptoms and support better health, but avoiding exercise for 4 hours before bed
• avoiding stimulants such as caffeine and nicotine, especially in the afternoon and evening
• refraining from drinking alcohol or only drinking it in moderation
• developing strategies for managing daytime stress to prevent negative thoughts from keeping a person awake or triggering joint pain
• eating a balanced meal a few hours before bed and trying a light snack just before bed if nighttime hunger is a problem
• using the bed only for sleeping and sex and not for watching television or doing work
• keeping the bedroom cool and dark, potentially by using blackout curtains
• investing in a comfortable, supportive mattress and quality pillows
• trying different pillow positioning, such as putting a pillow between the knees or under the hips, to ease joint pain

While they are working on improving their sleep hygiene, a person may find it helpful to get back up if they cannot fall asleep. Doing this helps the association between bed and sleep remain strong.

Develop an arthritis pain management strategy

A person can work with a doctor to develop a plan for managing arthritis pain.

Where possible, it is important to avoid going to bed in pain. A doctor can recommend an appropriate pain relief medication to prevent pain before bedtime. They might suggest:

• nighttime release arthritis drugs
• drugs that work for 24 hours
• an evening dose of pain medication

Identifying and managing arthritis triggers can also be helpful. A person can try keeping a pain and sleep log to determine and address any patterns that seem to worsen sleep or pain.

Consider psychotherapy

Being in pain night after night can affect a person’s emotional well-being and cause them to experience more pain. A 2017 study of people with knee OA found that people with sleep issues tend to catastrophize and focus on their pain, intensifying both pain and insomnia.

Therapy can help a person better cope with their pain and deal with daytime stressors that undermine sleep. Cognitive behavioral therapy for insomnia (CBT-I) is an evidence-based intervention that assists a person with learning new skills for sleeping better.

Summary

Nighttime arthritis pain is common. However, having arthritis does not mean that a person has to live with chronic sleep deprivation. The right combination of medications, sleep hygiene practices, and lifestyle adjustments may help a person sleep better and for longer.

People with arthritis should be aware that while pain can make sleep worse, low quality sleep can also intensify pain and increase stress. This can create a vicious cycle that arthritis medication alone may not be sufficient to break.

The best path to complete relief is to treat both insomnia and arthritis. A person can work with their doctor to create a treatment plan that addresses the two conditions.