Specialist article: Sleep
Daytime tirednessWhen sleep is not restorative
You get enough sleep and are still constantly tired? Here you will find out which causes can lie behind daytime tiredness, from sleep hygiene to sleep apnoea and reflux to mouth breathing during sleep, and why, in our view, restorative sleep is a question of breathing, swallowing and head balance.
Does this sound familiar?
Slept enough, and still feel worn out?
What applies to you?
Tap whatever applies to you.
If several points apply, it is worth taking a look at your night. Some causes lie in habits, others in the way you breathe and swallow during sleep. These patterns can be trained too.
Overview of causesMouth breathing during sleepThe key points at a glance
- Tired despite enough sleep often means that the sleep was not continuous. Fragmented sleep is less restorative than continuous sleep, even if the hours are sufficient.
- The causes range from light, caffeine and alcohol in the evening to sleep apnoea and night-time reflux to mouth breathing during sleep. They are often connected.
- CPAP is an effective support in sleep apnoea. Like a crutch, the device takes work off the throat, but it does not train the pattern behind it. In our view, this is where training breathing, swallowing and head balance comes in; sleep medicine decides on changes to the device.
Video
Daytime tiredness: causes and the role of breathing and sleep
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Terms
Tired, sleepy, exhausted: what daytime tiredness means
People who say they are constantly tired do not necessarily mean the same thing. The distinction helps to narrow down the cause.
Sleep is not a uniform state. Several times a night, the brain goes through a cycle of light sleep, deep sleep and dream sleep, known as REM sleep. A night becomes restorative when these cycles run undisturbed. In deep sleep, the parasympathetic nervous system predominates, the part of the nervous system responsible for rest and regeneration.
It is not the hours in bed that matter, but whether sleep is continuous.Brief arousals that you do not remember in the morning can split a night into many pieces. Seven hours in pieces are less restorative than seven hours in one stretch.
A review from Chicago has summarised the research on fragmented sleep. Fragmented sleep is less restorative than continuous sleep and leads to sleepiness and impairments during the day1. At the same time, it emphasises that this is not the only factor.
That is why it is worth looking at everything that fragments sleep. Some of it comes from outside, some arises in the body itself, for example in the throat or in the oesophagus.
Overview
Causes of daytime tiredness: five areas
If you want to find out why you are tired during the day, you can roughly sort the causes into five areas. Often several of them act together.
External factors
Light, noise, warmth in the bedroom, shift work or a partner who snores. They disturb sleep from the outside.
Sleep hygiene
Screens in the evening, caffeine in the afternoon, alcohol as a sleep aid, irregular hours. These habits shift or fragment sleep.
Sleep apnoea
During sleep the throat repeatedly narrows or collapses. Each arousal reopens it and fragments sleep in the process.
Night-time reflux
Gastric juice rises into the oesophagus when you are lying down. At night it stays there longer than during the day and can disturb sleep.
Night-time mouth breathing
If the mouth is open during sleep, the airway becomes narrower and the mouth dries out. In our view, mouth breathing is often at the beginning of snoring and breathing pauses.
The last three areas play out in the same place, in the mouth, nose and throat, and depend on the same basic functions: breathing, swallowing and head balance. That is why they often occur together.
Tiredness can also have other causes, for example anaemia, an underactive thyroid, depression, a lingering infection or side effects of medication. If it persists for weeks even though you sleep enough, have it clarified by a doctor.
Sleep hygiene
Light, caffeine, alcohol: what disturbs sleep from outside
Some causes of daytime tiredness lie in habits that are within your own control.
In the evening the brain needs the signal that the day is coming to an end. This signal comes mainly through light. Darkness makes the sleep hormone melatonin rise, bright and bluish light slows it down.
A quiet, dark and rather cool bedroom, fixed times for going to bed and getting up, and an evening routine without work or screens help the body find its rhythm.
You read in the evening before going to sleep. Which leaves you more alert the next morning?
Caffeine also acts for longer than many people think. In a study from Detroit, participants were given 400 milligrams of caffeine, either immediately before going to bed, or three or six hours beforehand. In all three cases sleep was measurably disturbed. The authors advise avoiding larger amounts of caffeine for at least six hours before bedtime3.
Many people regard alcohol as a sleep aid, and it is true that you fall asleep faster with it. A review from London, however, shows the whole picture. The first half of the night becomes deeper, the second more restless. Dream sleep starts later and, at moderate and high amounts, is shorter over the night4.
Sleeping pills and sedatives dampen the brain, but they do not restore the natural sleep sequence. The cause of a fragmented night remains, and in our view they are not intended as a permanent solution. Nevertheless, do not stop prescribed medication on your own; discuss any change with your practice.
Sleep apnoea
Sleep apnoea: when the airway gives way at night
One of the most common physical causes of daytime tiredness takes place in the throat.
The pharynx is a soft tube without a rigid framework. During the day, the tongue, soft palate and pharyngeal muscles keep it open. During sleep, their tension decreases. If the airway narrows, tissue starts to flutter and you snore. If it closes completely or almost completely, breathing stops, in obstructive sleep apnoea for at least ten seconds.
How snoring and breathing pauses are connected is explained in detail in the article Snoring and sleep apnoea.
The airway narrows
During sleep the tension in the throat decreases and the airflow falters.
Oxygen falls
Carbon dioxide rises, the drive to breathe gets stronger, the body comes under pressure.
The brain raises the alarm
A brief arousal tenses the muscles and opens the airway. As a rule, you will not remember it.
Sleep breaks apart
The sympathetic nervous system kicks in, pulse and blood pressure rise. Deep sleep hardly occurs this way.
The day becomes heavy
After many nights like this you are tired during the day, even though you spent long enough in bed.
of men in a population study from Lausanne had 15 or more apnoeas and hypopnoeas per hour of sleep. The study examined 2,121 people aged between 40 and 855
of women in the same study were above this value5
of the 3,250 people from 24 studies changed the severity class of their sleep apnoea at least once between two measurement nights. In 41 %, the number of respiratory events fluctuated by more than ten per hour11
The authors also attribute the high figures to more sensitive measuring technology5. Not everyone with an elevated value is tired during the day. A night in the sleep laboratory is a snapshot. The apnoea-hypopnoea index fluctuates from night to night11 and does not say how fragmented your sleep actually is. What matters is the course over weeks and how you feel during the day. That does not make a high value harmless; it makes it a reason to work on the cause.
Night-time reflux: when gastric juice disturbs sleep
Many people know heartburn from the daytime. During sleep, reflux behaves differently, and that is precisely what makes it significant at night.
In reflux, stomach contents flow back into the oesophagus. During the day this happens more often, but only briefly each time, because you swallow and saliva neutralises the acid. At night it is the other way round. Reflux events during sleep are less frequent but last considerably longer6.
The reason lies in protective mechanisms that weaken during sleep. Much less saliva is produced, you swallow less often, you barely notice the burning and do not wake up from it, and the stomach empties more slowly6.
At night the oesophagus is protected above all by things you do not even notice during the day: swallowing and saliva.Both decrease during sleep. That is why the swallowing pattern matters at night too.
The authors of the review name sleep apnoea and excess weight as factors that favour night-time reflux and describe that it can disturb sleep6. According to Dr. Berndsen’s model, the cause often lies not only at the entrance to the stomach, but also in the control.
If the act of swallowing is carried out in a compensatory way, then according to this model the strong nerve stimuli that trigger the reflex sequence via the vagus nerve and oesophagus down to the entrance of the stomach are missing. This chain has not been studied; it is his explanation based on function. Acid blockers take the acid out of the gastric juice, but they do not change the swallowing pattern. The training is not a reflux treatment; it addresses the swallowing pattern, one of the three basic functions. More on this in the article Swallowing and swallowing disorders.
If you often have heartburn, difficulty swallowing or a cough at night, or if you are losing weight unintentionally, have this clarified by a doctor.
Mouth breathing
Mouth breathing during sleep: an underestimated cause of tiredness
Whether you breathe through your nose or your mouth at night is something you hardly notice yourself. For the airway it makes a big difference.
Healthy adults breathe almost exclusively through the nose during sleep. A research group from Canada wanted to know why. They had twelve healthy people breathe during sleep alternately only through the nose or only through the mouth, and measured the resistance of the upper airways7.
was the median upper airway resistance during sleep with mouth breathing compared with nasal breathing. When awake, it was similar for both routes7
apnoeas and hypopnoeas were counted by the researchers with mouth breathing compared with nasal breathing, in the same healthy people7
The reason lies in the mechanics. When the mouth is open, the lower jaw drops, and the tongue slides down and back with it. The space in the throat becomes narrower. When the lips rest lightly together and the tongue lies against the palate in its tongue reference position, the oral cavity stays sealed and the air takes the route through the nose.
A blocked nose makes this worse. In a large population study from Wisconsin, people whose nose was blocked on five or more nights a month reported snoring, severe daytime sleepiness and unrefreshing sleep considerably more often8.
Dry mouth in the morning
Your tongue and palate are dry and sticky when you wake up.
Thirst at night
You wake up and reach for a glass of water.
Scratchy throat
Your throat feels rough in the morning without any infection.
Snoring
Whoever sleeps next to you can hear you, especially when you lie on your back.
Restless sleep
You toss and turn a lot and in the morning feel as if you had a short night.
Why we nevertheless do not tape the mouth shut at night is explained in the article Mouth taping. You can find more on dry mouth under Dry mouth, and on a blocked nose under Deviated nasal septum and Allergies and nasal breathing.
The triad
Restorative sleep is a pattern
Snoring, breathing pauses, night-time reflux and mouth breathing seem like separate problems. In our view, they share a common starting point.
Breathing, swallowing and head balance together form the triadic functional circuit. The nose breathes, the tongue settles against the palate after every swallow and seals the oral cavity, the head balances above the body. When these three run in the reference pattern, the airway stays stable during sleep as well.
If the pattern deviates, the body compensates. A head that drifts forward over a long period has, in our view, to be held constantly by muscles, and this holding work costs energy, during the day too. More on this in the article Neck and back.
The pattern deviates
Mouth breathing, a low-lying tongue or a forward head posture, often since childhood.
The body compensates
The nervous system stores the compensatory movement as the preferred pattern.
The tissue slackens
Muscles that are not integrated into their function are not used and lose tension. We call this functional hypotonia.
The night suffers
During sleep, voluntary control falls away. The airway narrows, the mouth opens, sleep breaks apart.
The day becomes tired
In our view, in many of those affected the tiredness is the last link in this chain, not its beginning.
The slackening is the symptom, not the cause.That is why we work on the pattern that produced the slackening. A pattern is learned, and it can be learned anew.
In our view, therefore, the cause of daytime tiredness does not usually lie in a single organ but in the interplay. How calm nasal breathing is linked to the nervous system for recovery is described in the article Stimulating the vagus nerve.
Putting aids into context
CPAP: an effective support
In moderate and severe sleep apnoea, positive airway pressure therapy is the standard. It works against tiredness for as long as it is worn.
A CPAP device blows air at slight positive pressure through a mask into the airways and splints the throat open from the inside. The breathing pauses stop and sleep becomes more continuous. That many people are more alert during the day with it has been well studied.
randomised, on CPAP in obstructive sleep apnoea, were analysed in a meta-analysis from Boston9
more than with placebo was the average reduction in sleepiness on the Epworth scale under CPAP, measured in 706 people9
was this advantage in studies with severe apnoea and marked sleepiness, and 1.10 points in the others9
Like a crutch
After a fracture, a crutch is exactly right. It helps carry the load as long as the leg cannot, and nobody puts it in the corner prematurely. But it does not teach walking, and in our view what is not used loses tension. That is how we see CPAP. The positive pressure keeps the airway open and takes work off the tongue, soft palate and throat. That is why long-term use does not remain without consequences, and alongside the support belongs training of the pattern that made it necessary.
CPAP is an acute support, not neurorehabilitation. Training the basic functions can be started in parallel. How treatments complement each other is described on the page FaceFormer and other treatments.
If you use a CPAP device, do not stop using it on your own. Whether positive airway pressure therapy can later be reduced or discontinued is shown by a follow-up measurement in the sleep laboratory. That decision rests solely with your sleep medicine specialist.
Training
Training the pattern: breathing, swallowing, head balance
If you want to work on the pattern of the night, you have to practise during the day. A breathing pattern is not a resolution but a stored sequence.
That exercises for the mouth, tongue and throat can change the night is shown by a randomised study from São Paulo. 31 people with moderate sleep apnoea practised for about 30 minutes a day for three months, either a programme for the tongue, soft palate and lateral pharyngeal wall or a sham therapy10.
was the drop in daytime sleepiness on the Epworth scale in the exercise group. In the control group none of the values changed significantly10
was the drop in the number of apnoeas and hypopnoeas in the exercise group; snoring and sleep quality also improved10
That was a different programme from FaceFormer training, and the figures cannot be transferred. But they show that the tension of the upper airways can be influenced by active practice. Our approach trains breathing, swallowing and head balance simultaneously in one sequence. What is available on FaceFormer training itself can be found on the page Studies and science.
In FaceFormer training, the FaceFormer sits in the oral vestibule, behind the lips and in front of the teeth. In the basic exercise you press the lip wedge together with your lips, bite down briefly and swallow. The negative pressure draws the tongue to the palate, the oral cavity is sealed, and the air takes the route through the nose.
From around week 6 the breathing exercise is added. You breathe in through your nose for six seconds, briefly hold your breath while biting down and swallowing, and breathe out for six seconds. You extend the pause afterwards week by week, only as far as feels comfortable.
- From day 1
Basic exercise
Three times a day for a few minutes with the FaceFormer ZERO, guided by the free app.
- After about 2 to 3 weeks
The night is added
At night you wear the ZERO as a supplement. If it slips out at first, that is normal.
- After a few weeks
Switching to the ONE
During the day, you train with the FaceFormer ONE. It is the same size and shape as the ZERO, just made of firmer material.
- From around week 6
Breathing exercise
Calm nasal breathing with breathing pauses that become longer over time.
- Over months
The pattern runs by itself
The exercise manual allows six to twelve months until the new sequences run without thinking.
The core is practising during the day. In obstructive sleep apnoea the training accompanies the sleep medicine treatment, and you coordinate nights with the CPAP mask with your sleep medicine specialist. You can find all modules on the exercise pages, and the time frame under Process and duration.
Everyday life
More alert through the day: what you can do yourself
Put screens away earlier
The last hour before sleep belongs to a book or a conversation in warm light.
Limit caffeine in the afternoon
Larger amounts of coffee, cola or energy drinks are best taken no later than six hours before going to bed.
No alcohol as a sleep aid
It makes the second half of the night more restless.
Fixed times
Try to go to bed and get up at the same time, at weekends too. A long afternoon nap can make it harder to fall asleep in the evening.
Lips closed, tongue up
Check several times a day whether your lips are resting lightly together and the tip of your tongue is resting on the palate behind your upper front teeth.
Head balance at the desk
Set up your screen and chair so that your head balances above your body and does not drift forward.
If you nod off unintentionally during the day, especially at the wheel, or if someone has noticed breathing pauses in you, have a measurement done in a sleep laboratory. It provides clarity and at the same time serves as the baseline against which you can read later changes.
Questions
Frequently asked
Why am I constantly tired even though I get enough sleep?
Because duration alone is not decisive. If sleep is broken up by brief arousals, for example due to breathing pauses, reflux or mouth breathing, it is less restorative. Add to that screen light, caffeine or alcohol in the evening. If the tiredness persists for weeks, also have anaemia or your thyroid checked.
What is the difference between daytime tiredness and daytime sleepiness?
Daytime tiredness describes a lack of drive and declining concentration. Daytime sleepiness is the tendency to nod off unintentionally during quiet activities. It is a typical sign of disturbed sleep, for example due to sleep apnoea. If you nod off at the wheel, have a measurement taken in a sleep laboratory.
Can sleep apnoea cause daytime tiredness?
Yes. In obstructive sleep apnoea, the throat repeatedly collapses during sleep. Each arousal opens it again, breaking up sleep in the process. However, not all tiredness is sleep apnoea; a measurement in a sleep laboratory provides clarity.
Can reflux make you tired?
Night-time reflux can disturb sleep. During sleep, less saliva is produced and swallowing occurs less often, so acid that has risen stays in the oesophagus for longer. If you have frequent heartburn, have it clarified by a doctor.
Does mouth breathing during sleep make you tired?
It can contribute. In a study with healthy people, upper airway resistance during sleep was more than twice as high with mouth breathing as with nasal breathing, and breathing pauses occurred considerably more often. We do not recommend taping the mouth shut.
Does CPAP help with daytime tiredness?
In obstructive sleep apnoea, CPAP reduces daytime sleepiness, most clearly in severe apnoea. The device works as long as it is worn. Whether it can later be reduced is shown by a follow-up measurement, and your sleep medicine team decides on this.
Can I train with the FaceFormer if I use CPAP?
Yes, training the basic functions can be started alongside positive airway pressure therapy. The core is practising during the day. How you manage the night is something you agree with your sleep medicine specialists.
What helps with tiredness in the afternoon?
In the short term, exercise, daylight and a short nap help. In the long run, it is worth looking at the night before, at screens, caffeine and alcohol in the evening, and at whether you breathe through your nose while asleep.
More articles from the knowledge section
Where to go next
Sources
- Stepanski EJ (2002). The effect of sleep fragmentation on daytime function. Sleep 25(3):268-276. PMID 12003157. Source
- Chang AM, Aeschbach D, Duffy JF, Czeisler CA (2015). Evening use of light-emitting eReaders negatively affects sleep, circadian timing, and next-morning alertness. Proceedings of the National Academy of Sciences 112(4):1232-1237. PMID 25535358. Source
- Drake C, Roehrs T, Shambroom J, Roth T (2013). Caffeine effects on sleep taken 0, 3, or 6 hours before going to bed. Journal of Clinical Sleep Medicine 9(11):1195-1200. PMID 24235903. Source
- Ebrahim IO, Shapiro CM, Williams AJ, Fenwick PB (2013). Alcohol and sleep I: effects on normal sleep. Alcoholism: Clinical and Experimental Research 37(4):539-549. PMID 23347102. Source
- Heinzer R, Vat S, Marques-Vidal P et al. (2015). Prevalence of sleep-disordered breathing in the general population: the HypnoLaus study. The Lancet Respiratory Medicine 3(4):310-318. PMID 25682233. Source
- Orr WC, Heading R, Johnson LF, Kryger M (2004). Review article: sleep and its relationship to gastro-oesophageal reflux. Alimentary Pharmacology and Therapeutics 20 Suppl 9:39-46. PMID 15527463. Source
- Fitzpatrick MF, McLean H, Urton AM, Tan A, O’Donnell D, Driver HS (2003). Effect of nasal or oral breathing route on upper airway resistance during sleep. European Respiratory Journal 22(5):827-832. PMID 14621092. Source
- Young T, Finn L, Kim H (1997). Nasal obstruction as a risk factor for sleep-disordered breathing. Journal of Allergy and Clinical Immunology 99(2):S757-S762. PMID 9042068. Source
- Patel SR, White DP, Malhotra A, Stanchina ML, Ayas NT (2003). Continuous positive airway pressure therapy for treating sleepiness in a diverse population with obstructive sleep apnea: results of a meta-analysis. Archives of Internal Medicine 163(5):565-571. PMID 12622603. Source
- Guimarães KC, Drager LF, Genta PR, Marcondes BF, Lorenzi-Filho G (2009). Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome. American Journal of Respiratory and Critical Care Medicine 179(10):962-966. PMID 19234106. Source
- Roeder M, Bradicich M, Schwarz EI, Thiel S, Gaisl T, Held U, Kohler M (2020). Night-to-night variability of respiratory events in obstructive sleep apnoea: a systematic review and meta-analysis. Thorax 75(12):1095-1102. PMID 32792405. Source
Get started
Ready for the training?
The free FaceFormer app guides you through the basic exercises, counts along and reminds you of your sessions. If you wish, a practice from the practitioner directory can support you.
FaceFormer ZERO + ONE
Both material hardnesses for getting started, day and night. The set for adults.
FaceFormer ZERO
The softer FaceFormer for getting started, for children and for the night.
FaceFormer ZERO Children’s Set
ZERO with hygiene box, plush bag and success book with stamp.
FaceFormer training aims to restore the physiological setting of the basic functions of breathing, swallowing and head balance, with lip closure and the tongue reference position, thereby creating the conditions under which symptoms can improve. It does not replace a medical assessment. You can find practitioners near you in the practitioner directory.
