Narcolepsy: Symptoms, Types, Diagnosis and Treatment

Narcolepsy is a lifelong brain condition that makes it hard to stay awake during the day, even after a full night of sleep. Other signs can include sudden muscle weakness with strong emotions (cataplexy), sleep paralysis, dreamlike images when falling asleep and broken night sleep. A sleep doctor confirms it with an overnight sleep study and a daytime nap test, and treatment can help most people stay alert at school, work and on the road.

What is narcolepsy?

In narcolepsy, the brain cannot keep sleep and wake in their proper places. Pieces of REM (dream) sleep slip into waking hours. That is why people with narcolepsy feel sleepy all day and may have dreamlike experiences while awake.^[1]

Narcolepsy most often starts in the teen years or young adulthood. One large study found two peaks in the age it begins: around 15 and around 35.^[2] Because the signs are easy to mistake for other problems, studies report that diagnosis is often delayed for years, up to about 15 years on average in some reports.^[3]

Narcolepsy type 1 and type 2

• Type 1 — daytime sleepiness plus cataplexy, or a low level of hypocretin (also called orexin) in the spinal fluid. Hypocretin is a brain chemical that helps keep you awake. In type 1, the brain cells that make it are lost, likely through an immune attack.^[1]
• Type 2 — daytime sleepiness and similar sleep test results, but no cataplexy, and hypocretin is normal or not measured. Some people with type 2 later develop cataplexy.^[4]

Symptoms of narcolepsy

• Heavy daytime sleepiness — the main symptom in everyone with narcolepsy. You may doze off in class, at work or while talking. Short naps can feel refreshing, but sleepiness soon comes back.
• Cataplexy — sudden, brief muscle weakness set off by strong emotions, often laughing. Knees may buckle, the head may drop or speech may slur. You stay aware the whole time.
• Sleep paralysis — being unable to move or speak for a short time when falling asleep or waking up.
• Hypnagogic hallucinations — vivid, sometimes scary dreamlike images or sounds when falling asleep or waking up.
• Broken night sleep — waking up many times during the night, even though you are sleepy during the day.
• Automatic behaviors — doing routine tasks, like writing or driving, with little memory of them.

Not everyone has every symptom. Sleep paralysis and hallucinations can also happen now and then in people without narcolepsy.

Narcolepsy in children and teens

Narcolepsy in young people is easy to miss. A sleepy child may seem lazy, moody or unable to focus, and is sometimes thought to have ADHD or depression.

• Sleepiness can look different — some children become hyper or irritable instead of looking tired, or start napping again after they had stopped.
• Cataplexy can look different too — in young children it may show up as a drooping face, an open mouth or a tongue that sticks out, not only as falls.
• School may suffer — falling asleep in class, slipping grades and trouble keeping up are common reasons families seek help.

Our pediatric sleep medicine page explains how children's sleep problems are evaluated.

How narcolepsy is diagnosed

• Sleep history — the sleep doctor asks about sleepiness, cataplexy and night sleep. Narcolepsy requires daily sleepiness for at least 3 months.^[4]
• Sleep diary and activity monitor — you track your sleep for a while, often with a wrist device, to make sure you are getting enough sleep before testing. See actigraphy sleep testing.
• Medicine review — some medicines can change test results. Your doctor may taper them before testing. Never stop a medicine on your own.
• Overnight sleep study — an in-lab study checks for other causes of sleepiness, such as sleep apnea.
• MSLT the next day — a series of daytime naps. Narcolepsy usually shows falling asleep in 8 minutes or less on average and REM sleep soon after falling asleep in at least 2 naps. Fast REM sleep on the overnight study can count as one.^[4] Read more in MSLT vs MWT.
• Spinal fluid test (sometimes) — measuring hypocretin can confirm type 1, but it is not needed for most people.^[4]

For a wider look at sleep testing, see how sleep doctors diagnose sleep disorders.

Treatment options

There is no cure yet, but treatment can help a lot. Plans are built around your symptoms, age and other health needs. The American Academy of Sleep Medicine reviewed the research in 2021. These are some of the options sleep doctors use:^[5]

• Wake-promoting medicines — such as modafinil, armodafinil, pitolisant and solriamfetol, which help with daytime sleepiness.
• Oxybate medicines — sodium oxybate, and a lower-sodium form, are taken at night. They can help sleepiness, cataplexy and night sleep. They need careful use under a doctor's watch.
• Stimulants — such as methylphenidate or amphetamine-type medicines, are another choice for sleepiness.
• Medicines for children — the AASM guideline suggests modafinil or sodium oxybate as options for children with narcolepsy.^[5]
• Healthy sleep habits — a regular sleep schedule, enough night sleep and short planned naps during the day.

Each medicine has side effects and safety rules, so the choice is made with your sleep doctor.

Staying safe at school, work and on the road

• Driving — never drive when drowsy. Talk with your sleep doctor before driving, and take a short nap before a drive if needed. Teens with narcolepsy should review driving with their doctor before getting a license.
• School — ask the school about a written plan that may include planned naps, extra time on tests and seating that helps your child stay alert.
• Work and hobbies — take extra care around heights, water, heavy machines and cooking until symptoms are under control.

When to see a sleep specialist

See a sleep doctor if you or your child:

• Are very sleepy during the day — for weeks or more, even after a full night of sleep.
• Fall asleep at the wrong times — in class, at work, while eating or while driving.
• Have muscle weakness with laughter or surprise — even if it lasts only a few seconds.
• Often have sleep paralysis or vivid images at sleep onset — especially together with daytime sleepiness.

Narcolepsy care in Cedar Park

Dr. Minal Patel is board-certified in pediatrics and sleep medicine and cares for both children and adults. Our practice offers in-lab sleep studies and narcolepsy evaluation with MSLT testing. We are accepting new patients. Office hours are Monday through Friday, 8:30 to 5:00. We accept Medicaid and CHIP for sleep patients. We do not take walk-ins.