Most ailments get worse at night, whether you are sick, or you are dealing with pain. There’s a simple reason for it; well two. It’s from the lack of two things: cortisol and movement.

Cortisol has a bad reputation as it’s known as the stress hormone. What that really means is that it’s the primary driver when your sympathetic nervous system is activated. This is the fight or flight response. I think of it as “on mode”. Cortisol liberates glucose from the muscle and liver into the bloodstream as a quick fuel source (as opposed to fats). When you are “on”, the body upregulates some systems of the body and downregulates others. This is a good thing as it prioritizes survival.

The sympathetic nervous system suppresses systems that aren’t vital when there is an emergency. For example, the digestive system (which is why you shouldn’t watch the news when you eat), and the reproductive system are suppressed. The immune system, which is responsible for the inflammatory response, is suppressed. So cortisol is an extremely potent anti-inflammatory. In fact, cortisone and steroids like prednisone are synthetic cortisol.

Remember that inflammation is the first step of the healing process and some powerful things happen during sleep to help you repair. So the combination of inflammation and repair at night is a good thing. Herein lies the problem. The body doesn’t have any vacant space so even a few cc’s of extra pressure hurts. We don’t want to suppress the immune system too much because we want healing to occur, however at a certain point, it becomes difficult to sleep which will impair healing.

Below is an example of what the daily pattern of cortisol looks like:

As soon as light hits your eyes, the sympathetic nervous system is triggered and you get a spike to start your day. Many of my patients tell me that their pain is bad in the morning, but once they get moving, it starts to go away. In part, this is due to the anti-inflammatory effect of cortisol.

By the way, melatonin has basically the opposite effect:

So you see that cortisol is lowest in the evening (in a healthy person). So that cold you’re fighting off, or that swollen knee gets worse. We don’t want to spike cortisol because that will inhibit melatonin production and it’ll be difficult to sleep. You may be thinking, “why not take an anti-inflammatory”? That will certainly reduce inflammation, but here is an important point. Inflammation and swelling are not the same thing. Inflammation is the initiation of the healing process, swelling is the waste product left behind. If there was a car accident on the highway, you wouldn’t want to set up a blockade before the scene of the accident; you’d want the ambulance to arrive. This is similar, you may be inhibiting the healing process. Not to mention it’s tough on the cardiovascular system and the gut. However, you do want to mitigate swelling.

So how do we do this? Swelling is handled by your lymphatic system. The lymphatic system is analogous to your cardiovascular system; where there are blood vessels, there are lymph nodes and channels. The cardiovascular system has a pump (the heart) to create circulation, whereas the lymphatic system does not. It relies on the pump action of muscles to create circulation. This is problem number 2 at night, you tend to not move as much so swelling is allowed to fester. This can also be the solution, gentle movement stimulates lymph flow. It doesn’t take much, and it works well.

Generally, you want to move the area that hurts in as pain free of a manner as possible, and then you’d want to follow up with belly breathing. The main duct of the lymph system is the cisterna chyli which rests under your diaphragm. So belly breathing presses on that duct and gets it to your upper chest where it drains. You may feel the urge to urinate after doing this and that’s a good thing, your body is getting rid of the waste. The bottom line is that you want to mitigate, rather than inhibit, the inflammation and swelling process.

Here are some examples:

For low back pain:

For knee pain:

For shoulder pain:

Why Pain is Worse at Night and What You Can do about it