Pain Really is Worse at Night: The Science Behind Nighttime Pain and Suggestions for Managing Nighttime Flares

(Warning: This is a longer post than usual. Because Painsomnia is such a serious challenge for nearly every Pain Warrior, I felt it was important to cover. If you have questions or any suggestions to add, please be sure to leave a comment.)

It’s not just your imagination—Painsomnia is very real and notoriously brutal. It is likely that you experience more pain at night. Changes in blood flow, hormone levels, and the lack of daytime distractions create a perfect storm once the sun goes down. Here’s the breakdown of why your body is acting up and some practical ways to push back.

Why Your Pain Spikes at Night

Part 1. Circulation Changes

Chronic pain is caused by a dysfunctional sympathetic nervous system, which controls your blood vessels. At night, your body naturally undergoes vasodilation (widening of blood vessels) to help lower your core temperature for sleep. For a healthy person, this is normal; for someone with chronic pain, this shift can trigger:

• Micro-inflammation: Increased blood flow to pain affected areas can cause throbbing or "burning" sensations. Your skin might get red and feel especially tender and sensitive. Sheets feel like sandpaper and wrinkles in your bedding can feel like a knife edge. Getting comfortable is not easy, and the more you worry about getting to sleep, the worse your affected areas burn.

• Temperature Sensitivity: The fluctuations between warm and cold can irritate damaged nerve endings. Temperatures can change as much as 5-10 degrees at night, even in an HVAC controlled home. The temperature outdoors varies even more widely in mountain and coastal areas. There are three important factors affecting temperature change:

  • Surface Temperature Changes: Even if the air temperature stays steady, your body loses heat to cooler surrounding surfaces like windows, floors, or walls. This can trigger vasoconstriction, the narrowing of blood vessels, causing muscles and joints to feel stiffer or sharper.

  • Bedding Temperature Changes: Conversely, mattresses and bedding (especially memory foam) can trap the heat your body sheds as your core temperature naturally drops. For those with neurologically based conditions like CRPS or fibromyalgia, this heat accumulation can activate TRPV1 receptors—the same sensors that detect painful heat—leading to a burning sensation that prevents deep sleep.

  • Hormonal Changes: Around 2:00 AM to 4:00 AM, the body reaches its lowest core temperature. During this dip, cortisol levels—the body's natural anti-inflammatory—are also at their lowest. This biological cooling combined with an external chill can create an environment where inflammation is less suppressed just as the nerves become more sensitive to cold.

Part 2. Cortisol Level Changes

Your natural anti-inflammatory hormone, cortisol, is at its lowest point at night. With less of this "natural ibuprofen" circulating in your system, the underlying inflammation and nerve signaling in your affected areas feel much more intense. Here’s how changes in cortisol affect your pain at night:

• Cortisol normally suppresses the production of cytokines (signaling proteins that trigger inflammation). Micro-inflammation in tissues increases, which chemically irritates already sensitized nerve endings. This is why joints feel throbbing or stiff and why your skin can feel raw in the middle of the night.   

• Cortisol has a stabilizing effect on nerve membranes. When levels are low, the threshold for a nerve to fire drops. Signals that your brain might ignore during the day (like the weight of a blanket or the minor pressure of your bladder) are suddenly perceived as "High Threat."  The stimulus hasn't changed, but the filter (cortisol) has vanished. 

• There is an inverse relationship between cortisol and Substance P (a neuropeptide that transmits pain signals). As cortisol drops, Substance P levels often rise. This enhances the "volume" of pain signals traveling to the brain, specifically making burning and aching sensations feel much more intense.

• As cortisol falls, melatonin rises. While melatonin is great for sleep, it can actually be pro-inflammatory in certain contexts. In a sensitized nervous system, this hormone shift can increase the sensitivity of pain receptors, particularly in the gut and bladder.

Part 3. Changes in Distractions

During the day, your brain is busy processing sights, sounds, and tasks. Distractions are actually a gift for someone living with chronic pain, as your focus is shifted away from your misery. At night, that "noise" disappears, leaving your brain with nothing to focus on except the pain signals. It’s like turning up the volume on a radio in a silent room. 

How to Compensate

We all know how important getting a good night’s sleep is - especially for Pain Warriors. There are natural opioid peptides that are created in the brain - but only when you are asleep. When pain starts to wind up just when you are trying to wind down, the goal is to "distract" your nervous system and stabilize your environment.

Temperature Management

• Not too hot, not too cold: Avoid heating pads or ice packs directly on painful areas, as extreme temperatures can trigger a flare. Instead, use lukewarm compresses to keep the temperature stable without overheating. Also, it is recommended that you wear loose fitting clothing, particularly pants, socks, and sleeves, and wear clothing made of natural fibers like bamboo or cotton. Avoid elastic at the neck, wrist  or ankle that might inhibit circulation and temperature control.

• Elevation: If blood pooling is an issue, slightly elevating your limb (above the heart) using a soft wedge pillow can help venous return and reduce the "throbbing" feeling.

Sensory Desensitization

• Fabric Therapy: If sheets feel like sandpaper, try using silk or high-thread-count satin bedding. Some people find relief by wearing a soft compression stocking to provide a "constant" sensation that helps the brain ignore the erratic nerve firings. If sheets are a problem, try sleeping on top of a plush throw or blanket as the texture provides reduced contact with your skin.

• White Noise & Distraction: Use a sound machine or a boring podcast. You might try an app that offers sleep stories. Insight Timer is considered one of the best free apps with thousands of stories and meditations to choose from. Calm, Sleepiest, HeadSpace, Slumber, and Better Sleep are great sources for night time distraction that leads to sleep. If your brain is busy processing audio, it has slightly less bandwidth for pain.

Resetting the System

• Vagus Nerve Stimulation: Gentle, deep diaphragmatic breathing before bed can help flip your nervous system from "Fight or Flight" (Sympathetic) to "Rest and Digest" (Parasympathetic), which helps stabilize blood flow. Box breathing or counting seconds between inhales and exhales also create a distraction.

• Magnesium: Oral magnesium is an important supplement for Pain Warriors. Talk with your medical provider about taking magnesium if it’s not part of your regimen. A topical magnesium spray  (I use one from Seven Minerals that I found on Amazon) or a warm (not hot) Epsom salt soak before bed can help relax vascular smooth muscles.

• Sleep Meditation: No Sleep Deep Rest Meditation or NSDR meditations can be found on YouTube, Insight Timer and other sites. My favorites are the ones recorded by Dr. Andrew Huberman with sessions varying in length from 10 minutes to 40 minutes in length. Another type of recording that many find beneficial is Yoga Nidra, or the yoga of sleep. These recordings are designed to help you relax, slow your thoughts, and drift off to sleep. Sleep researchers have found that the type of deep rest achieved with these practices can be as beneficial as hours of actual sleep. 

A Quick Reality Check

Chronic pain is a complex beast. If your nighttime pain is preventing sleep entirely, it’s worth chatting with your pain specialist or primary care provider about prescription medications like gabapentin (a medication for nerve pain), low-dose naltrexone (a medication that reduces inflammation in the brain and spinal cord when the dosage is under 6 mg.) or something like trazodone (an anti-depressant often used to help with insomnia). This article did not cover sleep hygiene, as I expect you have already tried all the basics. Hopefully you will find something here that will help you get a little more rest, even when your pain is high. Sweet dreams!