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What Can Make Narcolepsy Worse?

Medically Reviewed by Neha Pathak, MD on July 08, 2021

Narcolepsy disrupts nighttime sleep and causes attacks of sleepiness, and sometimes muscle weakness, during the day. With a condition that can interfere with your life in so many ways, you’ll want to do all you can to avoid anything that triggers your symptoms.

Narcolepsy is chronic, which means it will be with you for a long time. Though it isn't a progressive disease like multiple sclerosis, its symptoms can change over time. And certain things you do or don't do could lead to more sleep attacks.

"It may worsen or improve based on a person's sleep behavior," says Sogol Javaheri, MD, a sleep medicine physician at Brigham and Women's Hospital in Boston. "For example, sometimes people with narcolepsy may find that they can get by without napping during the day. That can be a big mistake, because sleep can never be replaced."

What Causes Narcolepsy?

Experts think narcolepsy comes from an autoimmune disorder. Most people with narcolepsy have very low levels of hypocretin, a chemical in the brain that helps you stay awake. A problem with the immune system causes it to attack the cells that produce hypocretin. The lack of this chemical is what leads to sleep attacks.

A drop in hypocretin is part of narcolepsy with cataplexy, where strong emotions, especially laughter or surprise, trigger a sudden loss of muscle tone. In movies, characters with cataplexy suddenly go limp, fall over, and hit the ground. In reality, the symptom isn't usually that dramatic, says Michael Awad, MD, chief of the Division of Sleep Surgery at Northwestern Medicine in Chicago and chief medical officer of PEAK Sleep.

"It tends to come on gradually," he says. "There are often no warning signs. As the person experiences strong emotions, they start to yawn and then they start to lose tone in their muscles. Some people get weak in the knees, while others lose muscle tone in their face."

Cataplexy may not first appear until months or even years after other narcolepsy symptoms. A low-dose antidepressant can help with this symptom.

Is a Virus to Blame?

One theory about the origins of narcolepsy is that a virus or other infection tricks the immune system into attacking hypocretin-producing cells. "The onset of narcolepsy symptoms most commonly occur in late spring, suggesting that the disease may be triggered by winter infections," Javaheri says.

About two-thirds of people diagnosed with narcolepsy test positive for antibodies against streptococcus, the bacteria that cause strep throat. Cases of narcolepsy rose after the 2009-2010 H1N1 influenza virus pandemic in China. And in several European countries, many children who received the Pandemrix vaccine, which protects against the H1N1 virus, were diagnosed with narcolepsy.

Infections don't seem to cause narcolepsy on their own, though. Many of the people who developed narcolepsy after they got the Pandemrix vaccine also carry a gene called GDNF-AS1. "It suggests that a combination of genetic predisposition, young age, and specific immune stimuli increase the risk of narcolepsy," Javaheri says.

You can get tested for gene changes linked to narcolepsy. But unless you have a family history of the condition, it may not be worth it, she adds.

Avoiding Sleep Attack Triggers

A problem controlling the normal sleep-wake cycles in narcolepsy causes the sudden attacks of sleepiness. "We don't believe that it is related as much to environmental factors," Awad says. But, he adds, "There are a lot of things people can do to improve the symptoms of narcolepsy."

One is to stick to a regular sleep schedule. Go to bed at the same time each night and wake up at the same time each morning. Try to get 7 to 8 hours of sleep a night. Make up for any sleep you miss during the day with naps. "Scheduling naps is really key," Javaheri says. "Try to time naps during the day before you hit the wall or feel really sleepy."

Avoid alcohol and caffeine, especially before bedtime. "Alcohol causes sleep fragmentation, which means that it breaks up our sleep," Awad says. Alcohol interrupts the restorative REM sleep stage, which can leave you feeling sleepy the next day, even when you feel like you've had a full night's sleep.

Alcohol also interacts with some of the medicines that treat narcolepsy. For example, taking the drug sodium oxybate (Xyrem) with alcohol can cause trouble breathing.

There's some evidence that the nicotine in cigarettes improves narcolepsy symptoms. But given the other health problems linked to smoking, "the risks strongly outweigh the benefits," Awad says. "There's also the concern, especially when people smoke in the afternoon or evening, if they have a sleep attack it could lead to burns or fires."

When to See Your Doctor

Narcolepsy is a chronic condition. It won't ever completely go away, but once you get on the right treatment, "you should be able to function," Javaheri says. "If your quality of life is significantly affected, that's an indication to see your doctor."

Symptoms like excessive sleepiness or trouble staying awake at school or work in someone who hasn't been diagnosed with narcolepsy are reasons to see a doctor for an evaluation, she says. Narcolepsy symptoms can overlap with mood disorders like depression and anxiety, and with sleep disorders such as obstructive sleep apnea. As a result, it can sometimes take years to get the right diagnosis.

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Sources

SOURCES:

National Institute of Neurological Disorders and Stroke: "Narcolepsy Fact Sheet."

National Organization for Rare Disorders: "Narcolepsy."

Sogol Javaheri, MD, MPH, sleep medicine physician, Brigham and Women's Hospital, Boston.

Michael Awad, MD, chief, Division of Sleep Surgery, Northwestern Medicine; chief medical officer, PEAK Sleep.

Sleep Science: "Infancy narcolepsy: Streptococcus infection as a causal factor."

PNAS: "H1N1 influenza virus induces narcolepsy-like sleep disruption and targets sleep-wake regulatory neurons in mice."

CDC: "Narcolepsy Following 2009 Pandemrix Influenza Vaccination in Europe."

EBioMedicine: "Pandemrix-induced narcolepsy is associated with genes related to immunity and neuronal survival."

Mayo Clinic: "Narcolepsy."

Journal of Clinical Sleep Medicine: "Narcolepsy with Cataplexy Masked by the Use of Nicotine."

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