Can a Cortisone Shot Cause Insomnia?

Cortisone shots can absolutely cause insomnia, and the effect is one of the more common side effects people report after joint or epidural injections. The steroid does not stay put in the joint where it was injected; it enters the bloodstream and reaches the brain, where it disrupts normal sleep-regulating pathways. The insomnia is usually temporary, but it catches many patients off guard because the injection feels like a local treatment rather than something that could affect sleep two rooms away from the shoulder or knee that got the shot.

How Common Is Insomnia After an Injection

Sleeplessness ranks among the most frequently reported side effects of corticosteroid injections, though pinning down a single prevalence number is tricky because studies measure it differently and patients do not always mention it to their doctor. In a large multi-institutional study of epidural steroid injections, a “central steroid response” that included sleeplessness, flushing, and nonpositional headache was documented in about 2.6% of patients.¹ That number likely undercounts the problem because it bundles insomnia together with other symptoms and relies on formal adverse-event reporting. Surveys that ask patients specifically about sleep tend to find higher rates. The broader psychiatric literature on corticosteroids lists insomnia alongside anxiety, mood swings, and irritability as effects that are “not rare” across various routes of steroid delivery.²

Part of the reason insomnia catches people off guard is that the injection site seems so far removed from the brain. When a doctor puts a needle into your knee or shoulder, you expect soreness at the injection site, not two nights of staring at the ceiling. But the steroid is designed to be slowly released from a depot in the tissue, and during that release, a meaningful fraction enters your general circulation.

Why a Local Injection Affects the Whole Body

The key to understanding the insomnia is that “local” injections are not truly local in their effects. Both joint injections and epidural injections can produce measurable systemic effects for weeks, including suppression of your body’s own cortisol production, blood-sugar spikes, and sleep disruption.³ The variability between individuals is large: some people absorb more of the drug into the bloodstream than others, and some are more sensitive to its brain effects. That is why your neighbor might sleep fine after the same injection that keeps you up for three nights.

Once the steroid reaches the brain, three main pathways contribute to sleep disruption. First, it modifies the hypothalamic-pituitary-adrenal (HPA) axis, which is the hormonal feedback loop your body uses to control cortisol levels. When that system gets flooded with an external steroid, it essentially confuses the body’s internal clock. Second, the steroid directly alters sleep-wake cycles. Third, it causes a kind of hyperarousal by changing the brain’s inhibitory signaling, making it harder for your nervous system to wind down.⁴ In plain terms, the steroid is simultaneously revving you up and throwing off the hormonal rhythm that normally tells your body when to feel drowsy.

What the Steroid Actually Does to Your Sleep

The disruption is not just “trouble falling asleep.” Corticosteroids change the internal structure of sleep itself. When researchers have given people cortisol or synthetic steroids and then monitored their brain waves overnight, a consistent pattern emerges: REM sleep drops significantly, and the time it takes to fall asleep tends to increase. In one pilot study that used portable EEG devices to track sleep after high-dose steroid pulse therapy, total sleep time fell from an average of about seven hours to under five hours on the first night, and REM sleep collapsed from over an hour to under ten minutes.⁵ Those doses were much higher than a typical joint injection, but the direction of the effect is the same.

The effect on deep sleep is more nuanced and depends on which type of steroid is used. Cortisol itself, the body’s natural glucocorticoid, tends to increase slow-wave sleep (the deep, restorative stage) through one set of brain receptors while simultaneously suppressing REM sleep through a different set.⁶ Synthetic steroids like dexamethasone, however, tend to reduce both REM and deep sleep, which may explain why some patients feel thoroughly unrested even when they do manage to sleep.⁷ Cortisol infusion has also been shown to increase highly synchronized slow brain-wave activity in the first few hours of the night, essentially pushing more deep sleep into the early part of the night while REM sleep shrinks overall.⁸

What this means practically is that after a cortisone shot, you might fall asleep at a normal time but wake up in the middle of the night and find it impossible to fall back asleep. Or you might lie in bed feeling oddly wired. Or you might sleep for a few hours but wake up feeling like you barely slept at all because REM sleep, the phase most associated with mental restoration, was cut short. The exact experience varies, but none of it is in your head: there are measurable changes happening in your brain’s electrical activity.

How Long the Insomnia Lasts

For most people who get a single joint injection, the sleep disruption peaks in the first one to three nights and resolves within a week. But the body’s hormonal recovery takes longer than the subjective insomnia. After a single injection, serum cortisol levels typically drop within hours and hit their lowest point around 24 to 48 hours later.⁹ Recovery to normal cortisol production generally takes one to four weeks, though sometimes longer depending on the drug used and the dose.

A study in athletes who received a single joint steroid injection found that two days later, nine out of ten participants showed biochemical signs of adrenal insufficiency. A week after the injection, cortisol levels were still only about half of their pre-injection values. Even at two weeks, cortisol levels averaged about three-quarters of baseline, and three participants still had abnormally low levels.¹⁰ This does not mean insomnia lasts two full weeks for everyone, but it does mean the hormonal ripple effect of a single shot extends well beyond the one or two bad nights most patients notice.

The formulation matters. Triamcinolone acetonide, a commonly used injectable steroid, has been associated with cortisol and ACTH suppression lasting seven to twelve weeks in some cases, depending on the dose and whether the patient received multiple injections.¹¹ For a typical single injection, however, full HPA axis recovery has been documented within as little as two weeks.¹² The practical takeaway is that sleep usually returns to normal well before your hormonal system does. If your insomnia persists beyond a week or two, something else may be going on and it is worth mentioning to your doctor.

Does the Dose or Type of Steroid Matter

Yes, and the relationship appears to be straightforward. Research on people taking ongoing oral glucocorticoids has found that sleep disturbance rises in a linear pattern as the dose increases.¹³ More steroid in your system means more disruption to the sleep-regulating pathways described above. This is consistent with what clinicians see in practice: a lower-dose injection into a small joint tends to cause milder or no sleep issues, while a larger dose into a big joint like the knee or hip is more likely to trigger a few rough nights.

Different steroid formulations are also absorbed at different rates, which affects how quickly and how intensely the drug hits the bloodstream. Methylprednisolone acetate, triamcinolone acetonide, and betamethasone are the most commonly used formulations in joint and epidural injections, and they differ in potency, duration of action, and solubility. Longer-acting depot preparations (like triamcinolone) tend to keep serum levels elevated for a longer period, which can extend the window during which sleep disruption occurs. Your doctor may already have a preferred formulation, but if insomnia has been a problem for you in the past, mentioning that when the injection is being planned is a reasonable conversation to have.

Who Is More Susceptible

The honest answer is that research has not nailed down a reliable profile for who will and will not get steroid-induced insomnia. There is significant individual variability in systemic absorption and clinical effects of locally injected steroids, and the reasons are not fully understood.³

A few patterns have emerged from broader steroid research. People who already have trouble sleeping seem to notice the effect more, which makes intuitive sense: if your sleep is fragile, the additional hormonal disruption is more likely to push you over the edge. Age may also play a role, with at least some evidence suggesting that older patients are more susceptible to steroid-related sleep problems, while younger patients may be more prone to behavioral changes.¹⁴ That evidence comes from the pediatric oncology literature rather than adult joint injections, so it does not translate perfectly, but the age-dependent pattern is biologically plausible given how cortisol receptor sensitivity changes over the lifespan.

People with a history of mood disorders or anxiety may also be more sensitive to the neuropsychiatric effects of steroids more broadly, including insomnia, agitation, and mood swings.¹⁵ If you have experienced steroid-related insomnia before, you are more likely to experience it again with a repeat injection. That track record is probably the single best predictor your doctor has to work with.

Practical Ways to Handle It

Because the insomnia is driven by a temporary hormonal surge, the most effective strategies focus on riding it out rather than fighting it. A few practical considerations can help:

Timing: If you have a choice, schedule the injection in the morning. Cortisol naturally peaks in the early morning and drops at night, so getting the shot early gives the initial absorption spike a better chance of aligning with your body’s normal rhythm rather than competing against it at bedtime.
Expectations: Knowing that one to three bad nights are likely takes some of the anxiety out of the experience. Lying in bed worried about why you cannot sleep makes the insomnia worse. If you know it is the steroid, you can treat those nights differently, perhaps reading or listening to something calm instead of clock-watching.
Sleep hygiene basics: The usual advice about keeping the room dark, cool, and screen-free matters more than usual during the post-injection window because your nervous system is already primed for wakefulness.
Over-the-counter options: Some patients find melatonin helpful in the first couple of nights. Discuss this with your doctor, particularly if you are taking other medications. Antihistamines like diphenhydramine can promote drowsiness but come with their own side effects, especially in older adults.
Communication: If insomnia has been a significant problem after a previous injection, tell your doctor before the next one. They may adjust the dose, choose a different formulation, or in some cases prescribe a short course of a sleep aid to cover the first few nights.

Avoiding caffeine and alcohol in the days following the injection is also sensible. Both can amplify the wakefulness that steroids induce, and alcohol in particular disrupts the same REM sleep that the steroid is already suppressing.

Insomnia Versus Other Neuropsychiatric Effects

Insomnia is the most common neuropsychiatric side effect of corticosteroids, but it does not always travel alone. The broader list of frequently identified symptoms includes agitation, anxiety, irritability, restlessness, mood swings, and difficulty concentrating.¹⁵ These symptoms can appear individually or in combination, and they tend to follow the same timeline as the insomnia, peaking in the first few days and fading as the steroid clears the system.

In rare cases with high doses or prolonged steroid exposure, more severe reactions such as psychosis, mania, or delirium have been reported.² These are extremely unlikely from a single joint injection, which delivers a much smaller systemic dose than the oral or intravenous courses typically associated with severe psychiatric effects. Still, if you notice symptoms that go well beyond trouble sleeping, such as racing thoughts, severe mood changes, or confusion, contact your doctor rather than assuming the shot is to blame and waiting it out.

Repeated Injections and Cumulative Exposure

A single cortisone shot is unlikely to cause lasting sleep problems, but many people with chronic joint conditions receive injections on a recurring schedule, often every three to six months. Each injection temporarily suppresses the HPA axis, and while the body recovers between injections in most cases, the cumulative exposure to synthetic steroids raises questions about whether the sleep effects compound over time.

Research on ongoing oral glucocorticoid therapy shows that sleep disturbance increases in a linear dose-dependent fashion, suggesting that higher total exposure translates to more disruption.¹³ Whether periodic injections produce the same cumulative pattern as daily oral dosing is less clear, because the body has weeks to recover between shots. Anecdotally, some patients report that the insomnia gets worse with each successive injection, while others say they barely notice it after the first time. If you find that the sleep disruption is worsening with repeated injections, it is worth discussing alternative pain management approaches with your doctor, including hyaluronic acid injections, physical therapy, or platelet-rich plasma, which do not carry the same hormonal baggage.

The broader concern with frequent steroid injections is not limited to sleep. Repeated exposure can contribute to bone density loss, cartilage thinning, and elevated blood sugar, which is why most guidelines recommend limiting injections in the same joint to three or four per year.³ Sleep disruption is just one more reason that spacing injections out and using the lowest effective dose is a sound strategy.

1
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2
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3
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4
PubMed Central. Steroid-Induced Sleep Disturbance and Delirium: A Focused Review for Critically Ill Patients
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PubMed Central. Sleep Architecture Alterations Following High-Dose Steroid Pulse Therapy: A Pilot Study Using a Portable Electroencephalogram-Based Device
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11
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12
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13
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PubMed Central. Risk factors for steroid-induced adverse psychological reactions and sleep problems in pediatric acute lymphoblastic leukemia: A systematic review
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