You lie there with the mask on, wide awake, mind racing the same way it did before you ever heard of CPAP. Instead of the mask helping you sleep, it becomes one more thing to think about. You notice every sensation, the air pressure, the strap tension, the sound of your own breathing, and that awareness keeps you alert instead of letting you drift off. Some nights you end up ripping the mask off out of frustration, telling yourself you’ll try again tomorrow, and then dreading bedtime the next night because you remember how hard it was.

Why this happens

When insomnia and sleep apnea occur together, it’s called COMISA, and it’s common. It shows up in roughly 30 to 50 percent of people with sleep apnea.¹ The mask itself doesn’t cause insomnia, but it adds a new physical sensation right at the moment your brain is already primed to stay alert and watch for reasons it won’t be able to sleep. This creates a loop. The harder you try to fall asleep with the mask on, the more your body treats bedtime as a stressful event rather than a wind-down, and that heightened alertness makes both the insomnia and the mask tolerance worse over time.

Steps to troubleshoot

1. Practice wearing the mask while awake during the day, watching TV or reading, so your brain stops associating it only with the pressure to fall asleep
2. Use a ramp setting so the pressure starts low and builds slowly, giving your body time to adjust instead of hitting full pressure right away
3. Keep your regular wind-down routine before bed and put the mask on as the very last step, not the first
4. Avoid checking the clock or lying in bed frustrated. If you’re awake more than 20 minutes, get up, do something calm in dim light, and go back to bed when sleepy
5. Keep your sleep and wake times consistent, even on weekends, since irregular timing makes both insomnia and CPAP adjustment harder
6. Ask about cognitive behavioral therapy for insomnia (CBT-I), which is the first-line treatment for insomnia and has been shown to also improve CPAP use in people with COMISA

Who to talk to

Your sleep doctor should know about the insomnia specifically, since treating it alongside the sleep apnea gets better results than treating either one alone. Your respiratory therapist can help with ramp settings, pressure comfort features, and mask desensitization strategies to reduce the physical trigger. Your DME can walk you through the comfort settings on your specific machine model. If the insomnia is significant, ask your sleep doctor about a referral to a CBT-I provider, since this is considered the gold standard treatment for insomnia and works well even when sleep apnea hasn’t been fully resolved yet.

Evidence

Insomnia and obstructive sleep apnea overlap far more often than once thought, and when they do, people use CPAP for fewer hours per night than people with sleep apnea alone.² Reviews of this relationship report that untreated insomnia symptoms reduce both the initial acceptance of CPAP and how consistently people stick with it over time.¹ This has shifted clinical guidance toward treating both conditions together rather than assuming CPAP alone will resolve the sleep difficulty.

References

1. Sweetman A, Lack L, McEvoy RD, et al. Bi-directional relationships between co-morbid insomnia and sleep apnea (COMISA). Sleep Med Rev. 2021;60:101519.
2. Sweetman A, Lack L, Bastien C. Co-morbid insomnia and sleep apnea (COMISA): prevalence, consequences, methodological considerations, and recent randomized controlled trials. Brain Sci. 2019;9(12):371.