Insomnia and Sleep Apnea: Which to Treat First?

By Brandon Peters, MD

More often than is recognized, difficulties breathing during sleep that characterize sleep apnea may prompt sudden awakenings, light sleep, and insomnia. As sleep degrades, increased anxiety and extended time in bed may make it hard to fall asleep at the start of the night. Not everyone with sleep apnea has textbook symptoms of the condition. Many people are surprised to learn they have it. When both conditions are recognized, which should be treated first and why? Consider the quandary that exists when you cannot fall asleep, but treatment may keep you awake.

Missing the Signs of Sleep Apnea

First, many people with insomnia have undiagnosed sleep apnea. Sleep apnea occurs when the throat is recurrently blocked by the base of the tongue and the soft palate, leading to difficulty breathing during sleep. Oxygen levels drop, carbon dioxide levels increase, and the brainstem prompts a sudden awakening to restore breathing. A burst of cortisol floods the body. This awakening fragments sleep, undermining its quality, and it may lead to insomnia.

Pause for a moment and consider some of the potential symptoms of sleep apnea:

  • Snoring

  • Gasping or choking

  • Witnessed pauses in breathing

  • Teeth grinding or clenching (bruxism)

  • Frequent urination at night (nocturia)

  • Heartburn at night

  • Palpitations (irregular heartbeats)

  • Night sweats

  • Dry mouth or drooling

  • Morning headaches

  • Frequent awakenings

  • Unrefreshing sleep

  • Excessive daytime sleepiness

  • Fatigue

  • Memory problems

  • Mood disorders (anxiety, depression, and irritability)

None of these symptoms have to be present to make the diagnosis of sleep apnea. Though many overlap with the condition, it is common for many to be absent. Testing to evaluate breathing, including home sleep apnea tests and in-center diagnostic polysomnograms, may bring the difficulty to light.

The Common Overlap Between Insomnia and Sleep Apnea

According to the International Classification of Sleep Disorders, by definition, insomnia occurs when there is difficulty initiating sleep, difficulty maintaining sleep, or when sleep is non-refreshing in the absence of another sleep disorder. Too often the neglected disorder contributing to the existence of insomnia is sleep apnea.

As reported elsewhere, many people with chronic insomnia have co-existing sleep apnea. It is a far more common association in older women, beyond the onset of menopause. Its very existence may be masked by the use of sleeping pills.

If ignored, the untreated sleep apnea will cause persistent awakenings, the failure of sleeping pills, and the insidious onset of conditions associated with sleep apnea (high blood pressure, diabetes, heart arrhythmias like atrial fibrillation, heart attack, heart failure, and even dementia).

When properly recognized, through evaluation and testing provided by a board-certified sleep physician, both conditions can be resolved and the long-term risks eliminated. The required testing may seem like a barrier when you already have difficulty sleeping, and the idea of treatment may seem like an impossibility.

Effective Treatments: CBTI, CPAP, Oral Appliances, and More

There are many available options to treat insomnia and sleep apnea. In the short term, sleeping pills may have their place. When used beyond a few months, cognitive behavioral therapy for insomnia (CBTI) becomes the preferred method to resolve insomnia.

Sleep apnea treatments may include continuous positive airway pressure (CPAP), an oral appliance from a dentist, weight loss, positional therapy, selective surgery, and other options. Most people are started on CPAP or fitted with an oral appliance to initially resolve difficulty breathing during sleep.

When someone already has trouble getting to sleep, the thought of putting on a mask that connects to a machine that blows pressurized air into your face may seem non-sensical. The idea of putting a large piece of plastic and metal into the mouth to hold the jaw and tongue forward may seem similarly preposterous. It raises an interesting dilemma: which treatment should be started first?

How to Choose the Right Order of Therapy

The sequence of testing and therapy should be based on individual preference and need. There is no right or wrong order when considering the diagnosis and treatment of co-existing insomnia and sleep apnea. Frankly, both must be resolved to restore normal sleep. Here are a few guiding principles:

  • Sleep-onset vs. Sleep-maintenance insomnia

It matters whether you have trouble getting to sleep at the beginning of the night or if you more often have frequent awakenings or wake towards morning with trouble returning to sleep. If you fall asleep instantly, chances are you will do the same with a test or treatment for sleep apnea. Frequent awakenings, if driven by sleep apnea, will resolve with effective breathing treatment. It may be unnecessary to pursue other treatment for the difficulty getting back to sleep if you don’t wake up until morning.

If you have trouble initiating sleep at the start of the night, however, it may be important to work through a CBTI program first. This may be especially true of you have significant anxiety or chronic pain.

  • Consider CBTI First

Research suggests that when both insomnia and sleep apnea are present, it is more effective to treat the insomnia with CBTI first. This can increase the compliance and response to sleep apnea treatment, including CPAP therapy. If you ignore the insomnia, it’s likely that the CPAP or oral appliance use will fail.

  • A Limited Role for Medication

In some cases, sleeping pills may be prescribed to ease the transition into sleep apnea treatment. This bridge therapy should be used over the short-term with physician supervision. The ultimate goal should be to stop these medications.

  • Seeking Professional Help

If you struggle with both insomnia and sleep apnea, reach out to a board-certified sleep physician or insomnia therapist who can guide you through the process of resolving the conditions. It is remarkable what a difference correcting these sleep disorders can have on daily function, overall health, and long-term quality of life.

Brandon Peters, MD, is the writer on sleep for, a neurology-trained sleep medicine specialist at Virginia Mason Medical Center in Seattle, and adjunct lecturer at the Stanford Center for Sleep Sciences and Medicine.


  1. Sweetman A, et al. Cognitive and behavioral therapy for insomnia increases the use of continuous positive airway pressure therapy in obstructive sleep apnea participants with co-morbid insomnia: A randomized clinical trial. Sleep 12 August 2019. doi:10.1093/sleepzsz178