A person who takes a long time to fall asleep, wakes up several times, and also snores loudly or has observed pauses in breathing may be dealing with more than one sleep problem. COMISA is the English acronym for comorbid insomnia and sleep apnea and describes the coexistence of insomnia and obstructive sleep apnea (OSA). One condition does not exclude the other — and recognizing both may help guide a more comprehensive evaluation.
COMISA is not a diagnosis that can be confirmed by a questionnaire, app, or online test. The investigation of insomnia and OSA involves distinct steps and should be conducted by a qualified professional, taking into account symptoms, medical history, and tests when indicated.
What is COMISA?
Insomnia involves persistent difficulty falling asleep, staying asleep, or returning to sleep after waking, despite having an adequate opportunity to rest. When the complaint recurs and affects daytime functioning, it warrants clinical evaluation. In adults, criteria used for chronic insomnia consider symptom frequency, duration, and daytime impact; one or two bad nights are not enough.
Obstructive sleep apnea occurs when the airway repeatedly narrows or closes during sleep. Snoring, pauses in breathing, choking, or awakenings may occur. Diagnosis depends on a clinical evaluation and a sleep study when indicated.
In COMISA, these two conditions occur together. The literature describes different frequency estimates depending on the population studied and the criteria used, so a single percentage does not represent everyone. Studies also associate their coexistence with a greater symptom burden and poorer daytime functioning, without proving that one condition causes the other in each individual.
What signs may occur?
Symptoms of insomnia may include taking a long time to fall asleep, prolonged awakenings, waking earlier than desired, and a feeling of unrefreshing sleep. During the day, some people report fatigue, irritability, difficulty concentrating, or persistent worry about sleep.
In OSA, signs that warrant attention include loud and frequent snoring, pauses in breathing noticed by another person, choking during the night, and daytime sleepiness. Some people do not notice the breathing episodes; therefore, an account from someone who sleeps nearby may be useful.
The presentation varies. Not all snoring means apnea, and not every nighttime awakening indicates chronic insomnia. What matters is the overall pattern, persistence, and impact of symptoms.
How is the evaluation conducted?
The clinical discussion may cover bedtime and wake-up times, awakenings, snoring, observed pauses in breathing, sleepiness, medications, health conditions, and daytime consequences. A sleep diary can help organize sleep times and symptoms; questionnaires may help with screening, but they do not replace medical evaluation or confirm OSA.
When apnea is suspected, the professional assesses whether a sleep study is necessary. Polysomnography records various physiological signals during the night; in certain situations, a specific home sleep apnea test may be considered. The choice depends on the clinical presentation and factors such as health conditions and the expected quality of the test. A single-night sleep study, on its own, also does not establish a chronic pattern of insomnia.
If a home test is negative, inconclusive, or technically inadequate despite persistent clinical suspicion, the professional may consider further investigation. Do not stop medications or change treatments to “improve” a test result without guidance.
How can both conditions be addressed?
The strategy is individualized and may include measures directed at each problem. For OSA, the treatment modality depends on the evaluation and diagnosis; positive airway pressure (PAP/CPAP) is one option when indicated. For chronic insomnia, cognitive behavioral therapy for insomnia (CBT-I) is a structured approach that can be discussed with a qualified professional.
Studies do not point to a single sequence that works for everyone. In a randomized trial involving 145 adults with OSA and insomnia, four sessions of CBT-I before CPAP were associated with greater average device use and greater initial acceptance compared with usual care. The MATRICS study, on the other hand, found improvements in insomnia measures with CBT-I before or alongside PAP, but observed no significant difference in PAP adherence between groups. These results show why it should not be promised that treating insomnia will increase CPAP adherence in everyone.
Sleep hygiene can support a routine, but it should not be presented as sufficient treatment on its own for chronic insomnia. Sleep medications, CPAP pressure, and other treatment decisions need to be discussed with the professional responsible for care; do not start, stop, or adjust anything on your own.
Frequently asked questions about COMISA
Is COMISA a separate disease?
The term describes the coexistence of insomnia and obstructive sleep apnea. It does not replace the individual evaluation of each condition.
Does having insomnia mean I cannot have apnea?
No. Both conditions can coexist. Habitual snoring, observed pauses in breathing, or nighttime choking should be mentioned during the evaluation, even when the main complaint is insomnia.
Does CPAP resolve insomnia?
Not always. CPAP is used for apnea when indicated, but persistent insomnia may require its own evaluation and approach.
Do I need polysomnography?
Not everyone with insomnia needs this test. When OSA or another disorder is suspected, the professional assesses which investigation is appropriate. Questionnaires and smartwatches do not replace that decision.
When should you seek an evaluation?
Talk to a professional if difficulty sleeping is persistent and affects daily life, or if there is frequent snoring, observed pauses in breathing, nighttime choking, or significant sleepiness. If you are sleepy at the wheel, do not drive; stop driving in a safe place and find an alternative.
This content is educational and does not replace an individual medical evaluation. The symptoms described do not confirm a diagnosis or indicate a specific treatment.
Sources consulted
- Ong JC et al. Sleep Apnea and Insomnia: Emerging Evidence for Effective Clinical Management.
- Sweetman A et al. Co-morbid insomnia and sleep apnea (COMISA): prevalence, consequences, methodological considerations, and recent randomized controlled trials.
- AASM Sleep Education. Comorbid Insomnia and Sleep Apnea (COMISA) Algorithm.
- Sweetman A et al. Cognitive and behavioral therapy for insomnia increases the use of CPAP therapy in obstructive sleep apnea participants with comorbid insomnia: a randomized clinical trial.
- Ong JC et al. A randomized controlled trial of CBT-I and PAP for obstructive sleep apnea and comorbid insomnia: main outcomes from the MATRICS study.