Hypersomnia is a disorder characterized by excessive daytime sleepiness (hypersomnolence), despite getting sufficient sleep at night. This condition involves an inability to stay awake and alert during waking hours, often leading to unintended lapses into drowsiness or sleep attacks. Hypersomnia significantly impacts daily functioning, reducing workplace productivity and increasing the risk of accidents. Treatment primarily aims to alleviate these symptoms and improve the individual’s overall quality of life.
Distinguishing Between Primary and Secondary Hypersomnia
Effective treatment depends on identifying the underlying cause, which requires distinguishing between primary and secondary hypersomnia. Primary hypersomnias, also known as central disorders of hypersomnolence, are neurological sleep disorders where excessive sleepiness is the main problem, not the result of another condition. Examples include Narcolepsy Type 1 and 2, and Idiopathic Hypersomnia.
Secondary hypersomnia arises as a symptom of a different medical condition, another sleep disorder, or a medication. Common causes include Obstructive Sleep Apnea (OSA), chronic pain, psychiatric disorders like depression, and certain prescription drugs. Diagnosis typically begins with a thorough medical history and the Epworth Sleepiness Scale, a subjective measure of sleepiness.
Specialized tests confirm the diagnosis. A Polysomnography (PSG) is an overnight sleep study that monitors brain waves, breathing, and body movements to rule out other sleep disorders like OSA. This is followed by the Multiple Sleep Latency Test (MSLT), which measures the tendency to fall asleep during the day; a mean sleep latency of eight minutes or less indicates pathological sleepiness.
Lifestyle and Behavioral Interventions
Before moving to pharmacological interventions, individuals can implement targeted lifestyle and behavioral changes to manage symptoms. Establishing a consistent sleep-wake schedule is foundational, helping to regulate the body’s internal circadian rhythm. This involves going to bed and waking up at the same time every day, including on weekends.
Optimizing the sleep environment is important, ensuring the bedroom is dark, quiet, and cool. Scheduled napping can be beneficial for some, particularly those with Narcolepsy, but timing and duration must be carefully controlled. Short, planned naps (typically under 20 to 30 minutes) can help manage acute sleepiness without interfering with nighttime sleep.
Substance use should be monitored, as alcohol and excessive caffeine intake can impair sleep quality and alertness. While caffeine offers temporary relief, consuming it too late can disrupt nighttime sleep. Regular, moderate-intensity physical activity, such as brisk walking or cycling, can also improve sleep quality and reduce daytime sleepiness, though exercise should be avoided close to bedtime.
Pharmacological Approaches
For individuals with primary hypersomnias, medication is often the most effective way to manage persistent excessive daytime sleepiness (EDS). Treatment is highly individualized and typically managed by a sleep specialist.
Wakefulness-Promoting Agents
First-line approaches involve wakefulness-promoting agents, such as modafinil and its longer-acting counterpart, armodafinil. These drugs enhance wakefulness and vigilance through mechanisms that differ from traditional stimulants. Modafinil is strongly recommended for both narcolepsy and idiopathic hypersomnia, typically initiated at a dose of 200 mg once daily.
Newer Medications
Newer medications approved for primary hypersomnias include pitolisant and solriamfetol. Pitolisant acts as a selective histamine 3 (H3) receptor antagonist/inverse agonist, increasing the release of histamine, a neurotransmitter that promotes wakefulness. Solriamfetol is a dual dopamine and norepinephrine reuptake inhibitor that improves the ability to maintain wakefulness.
Traditional Stimulants
Traditional stimulants like dextroamphetamine and methylphenidate are considered second-line treatments, reserved for when first-line agents are ineffective or contraindicated. These are Schedule II controlled substances due to their potential for dependence and abuse. Sodium oxybate is another specialized medication that is highly effective for excessive sleepiness and is also used to treat cataplexy in narcolepsy.
Treating Underlying Conditions
When hypersomnia is secondary, the focus shifts to resolving the underlying medical problem. Addressing the root cause is the most direct path to alleviating excessive daytime sleepiness, differing from simply masking the sleepiness with wake-promoting medications.
A common secondary cause is Obstructive Sleep Apnea (OSA), a disorder that causes repeated pauses in breathing during sleep and severe sleep fragmentation. The primary treatment for OSA is Continuous Positive Airway Pressure (CPAP) therapy, which delivers pressurized air through a mask to keep the airway open. Effective use of CPAP can resolve sleep fragmentation and eliminate the hypersomnia.
Another condition that can cause secondary hypersomnia is Restless Legs Syndrome (RLS), a neurological disorder that leads to an irresistible urge to move the legs, often disrupting sleep. Treatment for RLS may involve addressing an underlying iron deficiency or using medication, such as dopamine agonists. If hypersomnia is traced to a psychiatric disorder like major depression or a side effect of a prescription drug, treatment involves managing the mental health condition or adjusting the medication causing the drowsiness.