Pain Awareness Month: How Sleep and Chronic Pain Connect

Last updated: October 2026

September is Pain Awareness Month, and sleep belongs in that conversation. A review of prospective and experimental research concluded that sleep impairment is a stronger, more reliable predictor of pain than pain is of sleep impairment (Finan et al., 2013). In a meta-analysis of 12 randomized trials with 762 patients, cognitive behavioral therapy for insomnia (CBT-I) improved sleep in people with chronic pain, with a smaller effect on pain itself (Selvanathan et al., 2021). Below is what the research shows, what it does not, and where pillow height comes in.

Key takeaways

Sleep and pain affect each other, and sleep impairment is the stronger predictor of the two (Finan et al., 2013).
In 12 trials of patients with insomnia and chronic pain, CBT-I had a large effect on sleep (SMD 0.89) and a small effect on pain (SMD 0.20) (Selvanathan et al., 2021).
A Pillowise fitting takes three measurements (shoulder width, neck circumference and neck length) and adds sleeping position and bed type to choose from seven sizes.

Does poor sleep make pain worse?

A narrative review of prospective and experimental studies from 2005 onward found that, in population-based longitudinal studies, sleep impairments reliably predict new or worsening chronic pain (Finan et al., 2013).

Studies that tracked people day to day found sleep impairment was a stronger, more reliable predictor of pain than pain was of sleep impairment. Experimental work suggests poor sleep may weaken the body's own pain inhibition.

Which comes first, sleep problems or pain?

The relationship runs both ways, with sleep the stronger predictor (Finan et al., 2013). The review is narrative, so it gives no pooled numbers, and the proposed mechanisms are directions for future research rather than established findings.

Does treating insomnia help people with chronic pain?

A systematic review and meta-analysis included 12 randomized trials with 762 patients who had both insomnia and chronic non-cancer pain (Selvanathan et al., 2021).

After CBT-I, the effect on global sleep was large (SMD 0.89), the effect on depressive symptoms was moderate (SMD 0.44), and the effect on pain was small (SMD 0.20). Sleep was still improved at follow-up of up to 12 months (SMD 0.56). The authors estimated an 81% probability of better sleep after treatment and a 58% probability of less pain.

What do these studies not show?

The CBT-I trials show that sleep can improve meaningfully in people with chronic pain, while pain changes less. They do not show that improving sleep cures pain, and they apply to people with both insomnia and chronic pain (Selvanathan et al., 2021).

What does pillow height change overnight?

In a radiographic study of 16 adults, raising the pillow from 0 to 10 to 20 cm increased T1 slope and C2-7 Cobb angle while neck tilt decreased (Kim et al., 2015). A crossover study of 10 healthy participants paired with finite element modeling measured how heights from 110 to 170 mm shift pressure across the head and neck (Ren et al., 2016).

In a pilot EMG study of 15 adults lying on their side, the height matched to shoulder width produced the lowest neck and shoulder muscle activity (Jiao et al., 2025).

Why do generic pillows miss?

A standard contoured pillow, not fitted to the individual, performed no better than ordinary shapes in a randomized study of 106 side sleepers (Gordon et al., 2009). No single optimal pillow height can be specified, because it depends on four variables that differ from person to person: cervical alignment, body dimension, contact pressure, and muscle activity (Lei et al., 2021).

What we measure

Pillowise is a fitted cervical pillow that licensed healthcare providers measure and dispense, made in seven sizes.

Our sleep specialists take three measurements: shoulder width, neck circumference, and neck length. Combined with sleeping position and bed type, an algorithm identifies the best-fitting pillow from seven sizes.

Shoulder width is the measurement the EMG study found mattered most. A height matched to it produced the lowest neck and shoulder muscle activity during side sleeping (Jiao et al., 2025), and body dimension is what drives the individual optimum (Tian et al., 2025).

A systematic review of 11 studies covering 309 participants identified a 7 to 11 cm unloaded central height among the parameters supporting spinal alignment and sleep comfort (Radwan et al., 2021). The size is chosen from those three measurements plus sleeping position and bed type, rather than from a single stock height.

Pillowise pillows are made from premium Dutch memory foam and certified to OEKO-TEX Standard 100, meaning every component has been tested against the standard's limits for harmful substances.

Scope

The sleep and pain studies measured sleep, pain, and insomnia treatment, not pillows. No study has tested whether a fitted pillow changes chronic pain, and we make no such claim. The most recent systematic review found no clear advantage for any pillow type in chronic neck pain (Ghosh et al., 2025).

For providers

For patients with chronic pain, asking about sleep is part of a complete history, since sleep impairment predicts pain more reliably than the reverse.

Patients with persistent insomnia alongside chronic pain may benefit from a referral to a clinician trained in CBT-I.

A fitted pillow extends the work of the visit into the hours between visits, alongside the exercise, manual therapy, and other care the provider is already delivering.

Common questions

Can lack of sleep increase pain?

Longitudinal studies show sleep impairment reliably predicts new or worsening chronic pain, and it predicts pain more strongly than pain predicts poor sleep (Finan et al., 2013).

Does CBT-I reduce chronic pain?

Its effect on pain was small (SMD 0.20), while its effect on sleep was large (SMD 0.89) in 12 trials (Selvanathan et al., 2021).

Can a pillow help with chronic pain?

No study has tested that, and we make no such claim. A pillow fitting addresses head and neck height during sleep, which is part of a sleep setup rather than a pain treatment.

Is a contoured pillow from a store enough?

Not reliably. A standard contoured pillow, not fitted to the individual, performed no better than ordinary shapes in a randomized study of 106 side sleepers (Gordon et al., 2009), and no single optimal height can be specified because it depends on four variables that differ from person to person (Lei et al., 2021). A contour helps only if its height matches the person using it. That is what the fitting settles, in a provider's office.

Find a Pillowise provider or become one

Pillowise pillows are clinically measured and dispensed exclusively through licensed healthcare providers as part of broader sleep, posture, and recovery education.

To locate a Pillowise provider near you, visit: Find a Reseller

Licensed healthcare providers interested in offering Pillowise may register here: Become a Reseller

References

Finan, P. H., Goodin, B. R., & Smith, M. T. (2013). The association of sleep and pain: An update and a path forward. The Journal of Pain, 14(12), 1539-1552. https://doi.org/10.1016/j.jpain.2013.08.007

Ghosh, S. K., Goyal, M., & Goyal, K. S. (2025). Effect of pillow on pain, disability and sleep quality in patients with chronic neck pain: A systematic review. Rehabilitación, 59(3), 100922. https://doi.org/10.1016/j.rh.2025.100922

Gordon, S. J., Grimmer-Somers, K., & Trott, P. (2009). Pillow use: The behaviour of cervical pain, sleep quality and pillow comfort in side sleepers. Manual Therapy, 14(6), 671-678. https://doi.org/10.1016/j.math.2009.02.006

Jiao, R., Xiao, W., Wang, M., Yu, S., & Li, H. (2025). The impact of pillow height on neck muscle activity: A pilot study. Sleep and Breathing, 29(1), 40. https://doi.org/10.1007/s11325-024-03219-6

Kim, H. C., Jun, H. S., Kim, J. H., Ahn, J. H., Chang, I. B., Song, J. H., & Oh, J. K. (2015). The effect of different pillow heights on the parameters of cervicothoracic spine segments. Korean Journal of Spine, 12(3), 135-138. https://doi.org/10.14245/kjs.2015.12.3.135

Lei, J.-X., Yang, P.-F., Yang, A.-L., Gong, Y.-F., Shang, P., & Yuan, X.-C. (2021). Ergonomic consideration in pillow height determinants and evaluation. Healthcare, 9(10), 1333. https://doi.org/10.3390/healthcare9101333

Radwan, A., Ashton, N., Gates, T., Kilmer, A., & VanFleet, M. (2021). Effect of different pillow designs on promoting sleep comfort, quality, & spinal alignment: A systematic review. European Journal of Integrative Medicine, 42, 101269. https://doi.org/10.1016/j.eujim.2020.101269

Ren, S., Wong, D. W.-C., Yang, H., Zhou, Y., Lin, J., & Zhang, M. (2016). Effect of pillow height on the biomechanics of the head-neck complex: Investigation of the cranio-cervical pressure and cervical spine alignment. PeerJ, 4, e2397. https://doi.org/10.7717/peerj.2397

Selvanathan, J., Pham, C., Nagappa, M., Peng, P. W. H., Englesakis, M., Espie, C. A., Morin, C. M., & Chung, F. (2021). Cognitive behavioral therapy for insomnia in patients with chronic pain: A systematic review and meta-analysis of randomized controlled trials. Sleep Medicine Reviews, 60, 101460. https://doi.org/10.1016/j.smrv.2021.101460

Tian, S., Yao, C., Wang, Y., Cao, X., Sun, Y., Wang, L., & Fan, Y. (2025). The individualized optimal pillow height and neck support design for side sleepers. Medical and Biological Engineering and Computing, 63(2), 535-544. https://doi.org/10.1007/s11517-024-03204-x