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Excessive daytime sleepiness due to medical disorders and medications

Brian James Murray, MD, FRCPC D, ABSM
Section Editor
Thomas E Scammell, MD
Deputy Editor
April F Eichler, MD, MPH


Some patients have excessive daytime sleepiness (EDS) that is not caused by common disorders such as insufficient sleep, obstructive sleep apnea, or narcolepsy. This may manifest as excessive napping, inappropriate daytime sleep, or even accidents caused by falling asleep while driving or during other activities. In many cases, EDS is due to a treatable medical disorder, and proper diagnosis and treatment offers the possibility of improved daytime sleepiness along with improved medical outcomes.

This topic reviews medical and neurologic disorders associated with problematic sleepiness, beyond primary sleep disorders. An approach to the initial evaluation and management of a patient with EDS is presented separately. The evaluation and management of persistent sleepiness in patients with a known diagnosis of obstructive sleep apnea is also reviewed separately. (See "Approach to the patient with excessive daytime sleepiness" and "Evaluation and management of residual sleepiness in obstructive sleep apnea".)


Excessive daytime sleepiness (EDS) refers to the tendency to fall asleep in inappropriate settings. EDS is separate from fatigue, which can be manifested as difficulty or inability initiating activity, reduced capacity maintaining activity, and/or difficulty with concentration, memory, and emotional stability. Terms may be used interchangeably by patients, however, and it is not always possible to distinguish them by history alone. (See "Approach to the patient with excessive daytime sleepiness", section on 'Definitions' and "Approach to the adult patient with fatigue".)


Insufficient sleep is the most common and easily overlooked cause of excessive daytime sleepiness (EDS) [1]. In addition to a thorough history, a sleep log (table 1 and table 2) and actigraphy may help document the amount of sleep obtained and can identify factors contributing to poor sleep quality. High-risk groups include:

Shift workers, who tend to progressively accumulate sleep loss over time (see "Sleep-wake disturbances in shift workers")


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Literature review current through: Sep 2016. | This topic last updated: Jul 21, 2016.
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  1. Consensus Conference Panel, Watson NF, Badr MS, et al. Recommended Amount of Sleep for a Healthy Adult: A Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society. J Clin Sleep Med 2015; 11:591.
  2. Sterr A, Herron K, Dijk DJ, Ellis J. Time to wake-up: sleep problems and daytime sleepiness in long-term stroke survivors. Brain Inj 2008; 22:575.
  3. Johnson KG, Johnson DC. Frequency of sleep apnea in stroke and TIA patients: a meta-analysis. J Clin Sleep Med 2010; 6:131.
  4. Bassetti CL, Milanova M, Gugger M. Sleep-disordered breathing and acute ischemic stroke: diagnosis, risk factors, treatment, evolution, and long-term clinical outcome. Stroke 2006; 37:967.
  5. Goldstein LB. Potential effects of common drugs on stroke recovery. Arch Neurol 1998; 55:454.
  6. Collen J, Orr N, Lettieri CJ, et al. Sleep disturbances among soldiers with combat-related traumatic brain injury. Chest 2012; 142:622.
  7. Masel BE, Scheibel RS, Kimbark T, Kuna ST. Excessive daytime sleepiness in adults with brain injuries. Arch Phys Med Rehabil 2001; 82:1526.
  8. Watson NF, Dikmen S, Machamer J, et al. Hypersomnia following traumatic brain injury. J Clin Sleep Med 2007; 3:363.
  9. Baumann CR, Werth E, Stocker R, et al. Sleep-wake disturbances 6 months after traumatic brain injury: a prospective study. Brain 2007; 130:1873.
  10. Braley TJ, Segal BM, Chervin RD. Hypnotic use and fatigue in multiple sclerosis. Sleep Med 2015; 16:131.
  11. Klobucníková K, Carnická Z, Wagnerová H, Siarnik P. Is nocturnal epilepsy cause of disturbed quality of sleep and elevated daytime sleepiness? Neuro Endocrinol Lett 2014; 35:405.
  12. Jain SV, Glauser TA. Effects of epilepsy treatments on sleep architecture and daytime sleepiness: an evidence-based review of objective sleep metrics. Epilepsia 2014; 55:26.
  13. Cochen De Cock V, Bayard S, Jaussent I, et al. Daytime sleepiness in Parkinson's disease: a reappraisal. PLoS One 2014; 9:e107278.
  14. Thannickal TC, Lai YY, Siegel JM. Hypocretin (orexin) cell loss in Parkinson's disease. Brain 2007; 130:1586.
  15. Moreno-López C, Santamaría J, Salamero M, et al. Excessive daytime sleepiness in multiple system atrophy (SLEEMSA study). Arch Neurol 2011; 68:223.
  16. Weisman D, McKeith I. Dementia with Lewy bodies. Semin Neurol 2007; 27:42.
  17. Park M, Hood MM, Shah RC, et al. Sleepiness, parkinsonian features and sustained attention in mild Alzheimer's disease. Age Ageing 2012; 41:765.
  18. Brusse E, Brusse-Keizer MG, Duivenvoorden HJ, van Swieten JC. Fatigue in spinocerebellar ataxia: patient self-assessment of an early and disabling symptom. Neurology 2011; 76:953.
  19. Pedroso JL, França MC Jr, Braga-Neto P, et al. Nonmotor and extracerebellar features in Machado-Joseph disease: a review. Mov Disord 2013; 28:1200.
  20. D'Abreu A, França M Jr, Conz L, et al. Sleep symptoms and their clinical correlates in Machado-Joseph disease. Acta Neurol Scand 2009; 119:277.
  21. Lundkvist GB, Kristensson K, Bentivoglio M. Why trypanosomes cause sleeping sickness. Physiology (Bethesda) 2004; 19:198.
  22. Han F, Lin L, Warby SC, et al. Narcolepsy onset is seasonal and increased following the 2009 H1N1 pandemic in China. Ann Neurol 2011; 70:410.
  23. Sturkenboom MC. The narcolepsy-pandemic influenza story: can the truth ever be unraveled? Vaccine 2015; 33 Suppl 2:B6.
  24. Ahmed SS, Volkmuth W, Duca J, et al. Antibodies to influenza nucleoprotein cross-react with human hypocretin receptor 2. Sci Transl Med 2015; 7:294ra105.
  25. Overeem S, Dalmau J, Bataller L, et al. Hypocretin-1 CSF levels in anti-Ma2 associated encephalitis. Neurology 2004; 62:138.
  26. Lam EM, Shepard PW, St Louis EK, et al. Restless legs syndrome and daytime sleepiness are prominent in myotonic dystrophy type 2. Neurology 2013; 81:157.
  27. Gibbs JW 3rd, Ciafaloni E, Radtke RA. Excessive daytime somnolence and increased rapid eye movement pressure in myotonic dystrophy. Sleep 2002; 25:662.
  28. Kassardjian CD, Murray BJ, Kokokyi S, et al. Effects of napping on neuromuscular fatigue in myasthenia gravis. Muscle Nerve 2013; 48:816.
  29. Baets J, Duan X, Wu Y, et al. Defects of mutant DNMT1 are linked to a spectrum of neurological disorders. Brain 2015; 138:845.
  30. Bagai K, Song Y, Ling JF, et al. Sleep disturbances and diminished quality of life in postural tachycardia syndrome. J Clin Sleep Med 2011; 7:204.
  31. Stroe AF, Roth T, Jefferson C, et al. Comparative levels of excessive daytime sleepiness in common medical disorders. Sleep Med 2010; 11:890.
  32. Maas AP, Sinnema M, Didden R, et al. Sleep disturbances and behavioural problems in adults with Prader-Willi syndrome. J Intellect Disabil Res 2010; 54:906.
  33. Nevsimalova S, Vankova J, Stepanova I, et al. Hypocretin deficiency in Prader-Willi syndrome. Eur J Neurol 2005; 12:70.
  34. Vankova J, Stepanova I, Jech R, et al. Sleep disturbances and hypocretin deficiency in Niemann-Pick disease type C. Sleep 2003; 26:427.
  35. Shevell M, Ashwal S, Donley D, et al. Practice parameter: evaluation of the child with global developmental delay: report of the Quality Standards Subcommittee of the American Academy of Neurology and The Practice Committee of the Child Neurology Society. Neurology 2003; 60:367.
  36. Goldman SE, Malow BA, Newman KD, et al. Sleep patterns and daytime sleepiness in adolescents and young adults with Williams syndrome. J Intellect Disabil Res 2009; 53:182.
  37. Smith AC, Dykens E, Greenberg F. Sleep disturbance in Smith-Magenis syndrome (del 17 p11.2). Am J Med Genet 1998; 81:186.
  38. Wang D, Piper AJ, Yee BJ, et al. Hypercapnia is a key correlate of EEG activation and daytime sleepiness in hypercapnic sleep disordered breathing patients. J Clin Sleep Med 2014; 10:517.
  39. Kapsimalis F, Basta M, Varouchakis G, et al. Cytokines and pathological sleep. Sleep Med 2008; 9:603.
  40. Saper CB, Romanovsky AA, Scammell TE. Neural circuitry engaged by prostaglandins during the sickness syndrome. Nat Neurosci 2012; 15:1088.
  41. Westhovens R, Van der Elst K, Matthys A, et al. Sleep problems in patients with rheumatoid arthritis. J Rheumatol 2014; 41:31.
  42. Le Guen Y, Gagnadoux F, Hureaux J, et al. Sleep disturbances and impaired daytime functioning in outpatients with newly diagnosed lung cancer. Lung Cancer 2007; 58:139.
  43. Wolfe J, Orellana L, Ullrich C, et al. Symptoms and Distress in Children With Advanced Cancer: Prospective Patient-Reported Outcomes From the PediQUEST Study. J Clin Oncol 2015; 33:1928.
  44. Roscoe JA, Kaufman ME, Matteson-Rusby SE, et al. Cancer-related fatigue and sleep disorders. Oncologist 2007; 12 Suppl 1:35.
  45. Enderlin CA, Coleman EA, Cole C, et al. Sleep across chemotherapy treatment: a growing concern for women older than 50 with breast cancer. Oncol Nurs Forum 2010; 37:461.
  46. Allen RP, Barker PB, Wehrl FW, et al. MRI measurement of brain iron in patients with restless legs syndrome. Neurology 2001; 56:263.
  47. Sharma S, Efird JT, Knupp C, et al. Sleep disorders in adult sickle cell patients. J Clin Sleep Med 2015; 11:219.
  48. Newton JL, Reese JA, Watson SI, et al. Fatigue in adult patients with primary immune thrombocytopenia. Eur J Haematol 2011; 86:420.
  49. Newton JL, Gibson GJ, Tomlinson M, et al. Fatigue in primary biliary cirrhosis is associated with excessive daytime somnolence. Hepatology 2006; 44:91.
  50. Hanly P. Sleep apnea and daytime sleepiness in end-stage renal disease. Semin Dial 2004; 17:109.
  51. Shinno H, Inami Y, Inagaki T, et al. Successful treatment with levothyroxine for idiopathic hypersomnia patients with subclinical hypothyroidism. Gen Hosp Psychiatry 2009; 31:190.
  52. van der Klaauw AA, Dekkers OM, Pereira AM, et al. Increased daytime somnolence despite normal sleep patterns in patients treated for nonfunctioning pituitary macroadenoma. J Clin Endocrinol Metab 2007; 92:3898.
  53. Inkster B, Riha RL, Van Look L, et al. Association between excessive daytime sleepiness and severe hypoglycemia in people with type 2 diabetes: the Edinburgh Type 2 Diabetes Study. Diabetes Care 2013; 36:4157.
  54. Nandalike K, Strauss T, Agarwal C, et al. Screening for sleep-disordered breathing and excessive daytime sleepiness in adolescent girls with polycystic ovarian syndrome. J Pediatr 2011; 159:591.
  55. Campos-Ordonez T, Gonzalez-Perez O. Cyclohexane, a Potential Drug of Abuse with Pernicious Effects on the Brain. Front Pharmacol 2015; 6:291.
  56. Viaene M, Vermeir G, Godderis L. Sleep disturbances and occupational exposure to solvents. Sleep Med Rev 2009; 13:235.
  57. Guda N, Partington S, Shaw MJ, et al. Unrecognized GERD symptoms are associated with excessive daytime sleepiness in patients undergoing sleep studies. Dig Dis Sci 2007; 52:2873.
  58. Ito T, Yamadera H, Ito R, et al. Effects of vitamin B12 on bright light on cognitive and sleep-wake rhythm in Alzheimer-type dementia. Psychiatry Clin Neurosci 2001; 55:281.
  59. Kerley CP, Hutchinson K, Bolger K, et al. Serum Vitamin D Is Significantly Inversely Associated with Disease Severity in Caucasian Adults with Obstructive Sleep Apnea Syndrome. Sleep 2016; 39:293.
  60. Signal TL, Paine SJ, Sweeney B, et al. Prevalence of abnormal sleep duration and excessive daytime sleepiness in pregnancy and the role of socio-demographic factors: comparing pregnant women with women in the general population. Sleep Med 2014; 15:1477.
  61. Bourjeily G, Raker C, Chalhoub M, Miller M. Excessive daytime sleepiness in late pregnancy may not always be normal: results from a cross-sectional study. Sleep Breath 2013; 17:735.
  62. Rizo C, Deshpande A, Ing A, Seeman N. A rapid, Web-based method for obtaining patient views on effects and side-effects of antidepressants. J Affect Disord 2011; 130:290.
  63. Arnulf I, Leu-Semenescu S. Sleepiness in Parkinson's disease. Parkinsonism Relat Disord 2009; 15 Suppl 3:S101.
  64. Murphy PJ, Badia P, Myers BL, et al. Nonsteroidal anti-inflammatory drugs affect normal sleep patterns in humans. Physiol Behav 1994; 55:1063.
  65. Sutter R, Rüegg S, Tschudin-Sutter S. Seizures as adverse events of antibiotic drugs: A systematic review. Neurology 2015; 85:1332.
  66. Dzodzomenyo S, Stolfi A, Splaingard D, et al. Urine toxicology screen in multiple sleep latency test: the correlation of positive tetrahydrocannabinol, drug negative patients, and narcolepsy. J Clin Sleep Med 2015; 11:93.
  67. Zgierska A, Brown RT, Zuelsdorff M, et al. Sleep and daytime sleepiness problems among patients with chronic noncancerous pain receiving long-term opioid therapy: a cross-sectional study. J Opioid Manag 2007; 3:317.