There is no doubt that sleep and seizures are connected. Both affect and influence each other which can create many difficulties for someone with epilepsy.
In this article, we will explore the connection between epilepsy, seizures and sleep.
What are nocturnal seizures?
Nocturnal seizures refer to epileptic seizures that occur during sleep. While epileptic seizures frequently happen during the sleep state, unlike daytime seizures, nocturnal seizures may go unnoticed by the person experiencing them or be difficult to distinguish from sleep disorders and other nonepileptic events, especially if they are non-convulsive. This can make diagnosis challenging.
Many seizure types can happen during sleep. In many cases, people may only become aware of their nocturnal seizures through symptoms such as feeling unusually tired in the morning, experiencing muscle soreness, or waking up with a bitten tongue or injuries that could suggest a seizure took place. If people get out of bed and wander during their seizure, they may also notice things out of place around the house in the morning.
While many people with epilepsy have seizures during both sleep and wakefulness, several epilepsy syndromes have an especially strong link with seizure activity during sleep.
Sleep
Sleep plays a major role in our physical and mental well-being. We all need to sleep and have consistent good sleep patterns. It allows the brain and body to repair and restore themselves. Sleep impacts everything from cognitive function to immune system strength and mood regulation. Essentially, getting enough good quality sleep is vital for our health and well-being at any stage of life.
Poor sleep has a detrimental effect and creates tiredness and fatigue during the day which also interferes with work, thinking, learning, remembering things, managing your emotions, and social functioning.
As well as the possible risk of exacerbating seizures, not getting enough sleep also significantly affects cognition (learning, memory, concentration), socialisation, mental health and reduced overall quality of life. These areas are already impacted by epilepsy itself and its treatment.
Sleep disorders and epilepsy
Sleep disorders, poor sleep and daytime sleepiness are more common in people with epilepsy than in the general population. Sleep disorders typically cause poor sleep quality which is associated with poor seizure control.
Sleep disorders can also enhance many existing problems faced by people with epilepsy such as tiredness, learning, memory and mental health problems. They can worsen or trigger seizures, and sleep disorders can be exacerbated by seizures and by anti-seizure treatments. Sleep is, therefore, an important aspect of care that should not be overlooked. If there is a suspected sleep disorder, it should be tested for and treated.
The relationship between sleep and seizures
Sleep plays a fundamental role in the onset, frequency, duration and progression in seizures. Both the quality and quantity of sleep can influence the likelihood of seizures occurring.
The brain’s activity during sleep is complex and dramatically changes between different sleep stages. It’s thought that nocturnal seizures are triggered by these changes when moving between the different stages of sleep, and between sleep and awakening stage.
When we go to bed and shift from:
- wakefulness to drowsiness to
- light sleep to deep sleep to
- Rapid Eye Movement (REM) sleep,
- and this whole cycle occurs 3-4 times per night.
During sleep, epileptic features on EEG are also increased in some forms of epilepsy.
The interaction between sleep and seizure activity is two-way, meaning that while seizures can disrupt sleep patterns, poor sleep can, in turn, increase the likelihood of a seizure. Sleep deprivation is a well-known trigger for seizures, and inadequate or fragmented sleep may lead to more frequent or severe seizures.
The impact of nocturnal seizures on sleep quality
There is no doubt that nocturnal seizures impact sleep quality, which can have both short and long-term consequences. Seizures during sleep cause arousals and changes to sleep patterns, leading to sleep fragmentation. When someone has a nocturnal seizure, they may not fully awaken, but the sleep cycle is affected. Even a subtle seizure at the beginning of the night can cause disruption for the rest of the night.
These disruptions can lead to:
- Decreased sleep efficiency: The time spent in restorative stages of sleep, such as deep sleep and REM sleep, may be significantly reduced. This leads to a feeling of unrefreshing sleep and daytime sleepiness and fatigue.
- Sleep fragmentation: Nocturnal seizures can cause frequent awakenings or subtle disturbances that prevent continuous, restorative sleep. This sleep fragmentation may lead to cognitive difficulties the next day and feeling “brain fog”.
- Increased daytime sleepiness: Fragmented sleep caused by nocturnal seizures leads to excessive daytime sleepiness and reduced cognitive performance, which can impact work, school, and quality of life.
How do I know if I am having nocturnal seizures?
Unlike daytime seizures, which are often witnessed or reported, nocturnal seizures are typically harder to identify, especially if the person sleeps alone. Some of the common clinical signs of a seizure during sleep include:
- Morning headache: Post-seizure headaches are common. People who experience nocturnal seizures may wake up with a headache.
- Tongue or cheek biting or oral injuries: A bitten tongue or cheek are common signs that a nocturnal tonic-clonic seizure has occurred. This is due to muscle contractions during the seizure.
- Incontinence: In some cases, people may experience urinary incontinence during a seizure. In children, this may be mistaken for bed-wetting.
- Muscle soreness: The muscle contractions during some seizures can lead to soreness or stiffness, especially in the neck, shoulders, and limbs.
- Excessive sleepiness: Fragmented or insufficient sleep can leave people feeling unrefreshed in the morning and excessively tired during the day, even after what seems to be a full nights sleep.
Management
Managing nocturnal seizures really isn’t much different to managing daytime seizures. It requires a comprehensive approach, combining medical and lifestyle interventions.
- Antiseizure medications (ASMs): The primary treatment for epilepsy involves the use of medication. The choice of medication will depend on the type of seizure, its frequency, and the individual’s overall health. The dose and timing of antiseizure medication (and other medications) should be optimised to improve sleep and avoid daytime sedation. Taking medication regularly as prescribed is crucial to seizure control.
- Improve sleep: Since sleep deprivation is a known trigger for seizures, people with nocturnal seizures should prioritise good sleep hygiene. This includes keeping a regular sleep schedule, avoiding caffeine and alcohol, creating a bedtime routine, and ensuring a comfortable sleep environment. Improved sleep generally means less seizures.
- Get sleep disorders diagnosed: Anyone with a suspected sleep disorder should speak to their doctor to have a sleep study booked. Managing a sleep disorder will help with gaining seizure control.
- Seizure detection devices: For people with regular nocturnal seizures, wearable seizure detection devices can help alert caregivers or family members. These devices typically monitor movements and alert to specific movements, about a possible seizure. This can reduce risks associated with nocturnal seizures.
- Cognitive Behavioral Therapy (CBT): In some cases, CBT or relaxation techniques may be used to reduce anxiety and stress, which can exacerbate seizures and disrupt sleep. This can also lead to better sleep.
A note about SUDEP
It is important to note that nocturnal seizures are a risk factor for Sudden Unexpected Death in Epilepsy (SUDEP).
SUDEP happens in about 1 in 1000 people with epilepsy. The deaths are often unwitnessed with many occurring overnight during sleep. There may be obvious signs a seizure has happened, though this isn’t always the case. The cause of SUDEP is not yet clear.
For more about SUDEP, epilepsy and risk, CLICK HERE
Summary
- Sleep and epilepsy are connected and can create a vicious cycle of seizures and sleep deprivation if not managed.
- Sleep is disrupted by seizures.
- Seizures are triggered by sleep and sleep deprivation.
- Poor sleep is one of the most commonly reported seizure triggers by people with epilepsy.
- Poor sleep is also associated with worsened quality of life, psychological function, and memory.
- Improving sleep has been noted to improve seizure frequency and an overall well-being in people with epilepsy. Hence, an emphasis should be given to address sleep in people with epilepsy.
- Managing epilepsy is much more than just treating seizures.
References
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Berry, R.B. (2012). Nocturnal Epilepsy. Chapter 27 – Clinical Electroencephalography and Nocturnal Epilepsy. Fundamentals of Sleep Medicine. Pgs 545-566, ISBN 9781437703269, https://doi.org/10.1016/B978-1-4377-0326-9.00027-0
National Institute of Health (NIH) (2022) Sleep Deprivation and Deficiency: How Sleep Affects Your Health. Accessed 10 Feb 2025 https://www.nhlbi.nih.gov/health/sleep-deprivation/health-effects
National Institute of Health (NIH) (2022) How Sleep Works: Why Is Sleep Important? . Accessed 11 Feb 2025. https://www.nhlbi.nih.gov/health/sleep/why-sleep-important
Nobili, L., Beniczky, S., Eriksson, S.H., Romigi, A., Ryvlin, P., Toledo, M., and Rosenzweig, I. (2021) Expert Opinion: Managing sleep disturbances in people with epilepsy. Epilepsy & Behavior, Volume 124, 108341, ISSN 1525-5050, https://doi.org/10.1016/j.yebeh.2021.108341
Sejal V. Jain, Sanjeev V. Kothare. (2015) Sleep and Epilepsy. Seminars in Pediatric Neurology, Volume 22, Issue 2, Pgs 86-92, ISSN 1071-9091, https://doi.org/10.1016/j.spen.2015.03.005
Sleep Disruption in Epilepsy: Ictal and Interictal Epileptic Activity Matter https://onlinelibrary.wiley.com/doi/abs/10.1002/ana.25884
St. Louis, E. K., & Foldvary-Schaefer, N. (2021, May 25). Sleep-related epilepsy syndromes. In A. Y. Avidan & P. Garcia (Eds.). UpToDate. https://www.uptodate.com/contents/sleep-related-epilepsy-syndromes
https://www.epilepsy.org.au/about-epilepsy/epilepsy-and-risk/
