I have songs playing in my head 24/7. Not metaphorically — a constant, involuntary musical loop, all day, every day from the moment I wake up to the moment I sleep.
It could be any song that I've heard before — typically 5-15 second loops of a song I've heard recently. Sometimes it'll be background music of Instagram reels. Other times, it's something I haven't heard in years. It's there all day nonstop unless I'm listening to other music or if I'm extremely focused on something. As I write this, the song in my head is a clip from Professor Rowan's lab theme from Pokemon Diamond.
Having songs in your head sounds kind of nice at first, but gets really old within a few days. I couldn't get them to stop no matter what I did. I assumed that it would get better over time so I didn't worry about it. But after a few months, it didn't, and I realized there was something wrong beyond "just being tired and stressed".
It took me 3 years to identify with certainty what the root cause was, and it's been an ongoing effort for many years since then to figure out a solution.
After years of twists and turns, I concluded I have Upper Airway Resistance Syndrome (UARS). UARS is the most underdiagnosed sleep disorder you've never heard of. I've spent my entire adult life trying to solve it for myself.
I believe the songs in my head is one of the stranger manifestations of fragmented sleep.
I'm writing this because UARS is probably one of the most underdiagnosed conditions out there. If you're someone who feels brain foggy or tired all the time and can't figure out why, I hope this helps you identify a potential cause.
This is a brief summary of what I've learned — the clinical picture, the diagnostic pitfalls, the treatment ladder, and what actually helped.
Obligatory — not medical advice. Just my deep-dive into a condition most sleep doctors don't know or recognize.
UARS sits on the spectrum of sleep-disordered breathing, somewhere between normal and obstructive sleep apnea (OSA). The airway doesn't fully collapse like in OSA — instead, it narrows just enough to cause respiratory effort-related arousals (RERAs). You don't stop breathing. You just work harder to breathe, and your brain wakes you up dozens of times per night without you knowing.
The classic UARS patient looks nothing like the classic OSA patient. You can be young, thin, fit, and still have it. However, the symptoms can be just as strong, or worse. The hallmark symptoms are: chronic daytime fatigue, cognitive fog, attention problems, and unrefreshing sleep despite seemingly adequate hours.
My first in-lab sleep study came back with an AHI of 3.2 — technically "normal." But my RDI was 8.8. That gap is the UARS signature: few full apneas, lots of RERAs. Most sleep labs only report AHI, which means most UARS cases get missed entirely. A RERA means that you were woken up due to a breathing related event.
Looking back, the signs were always there. In 2005, when I was five, my family moved into a house I was deeply allergic to — previous owners had cats. Immediately, I was brain foggy, anhedonic, and miserable. My mom thankfully figured it out within a week and had us stay at a friend's house while she ripped out all the carpets from the house.
My sleep was never great. I also had restless leg syndrome as a kid — I was always squatting on chairs during the day because my legs wouldn't stay still, and at night I couldn't fall asleep until I was completely exhausted.
Then in 8th grade, once I hit puberty, my sleep got consistently worse. I felt noticeably dumber than I had been before. It was noticeably harder for me to focus in my classes. Learning was a bit slower than before, and it took me longer to solve math problems. I was falling asleep in first period. When I went on a trip to China, my relatives were surprised I was already snoring loudly all night, but my parents had gotten used to it by then.
In high school in general, I was barely awake for the first few periods of the day. There was one summer I took a class, Consumer Ed, that was particularly bad since my allergies were really flaring up in that particular classroom for whatever reason, where I had constant congestion. That's when I first started using daily Flonase. Overall though, it wasn't too bad. I felt maybe 80% compared to baseline. Maybe, imagine you get a week of 6 hours of sleep instead of 8-9. That's how I felt all the time.
It wasn't until 2019 after my freshman year of college, that the symptoms really intensified. I moved into an apartment with a severe dust mite problem. Within months I developed chronic nasal congestion, and my sleep quality tanked. The congestion caused my inferior turbinates to enlarge, and they never fully went back to normal, even after I moved out and the allergies improved.
Oftentimes, my attention was so shot that I couldn't read more than a sentence at a time. Constant pressure headaches. But worst of all, the songs in my head.
I've tried all sorts of things to get the songs to stop, from pharmacology to behavioral techniques. Meditation, not listening to music, listening to more music, etc. Improving my sleep regularity, going to the gym, etc.
It took me forever to find out the cause, due to misguidance from the entire medical system. And I did deep rabbit hole dives of internet research across various forums. Before I ever identified the airway as the problem, I chased every other explanation:
I had an at-home sleep study where the doctors just told me everything was normal, which threw me off the right track.
I saw allergists, ENTs, and sleep specialists before finally landing on UARS as the root cause. Everything else was a red herring.
UARS is hard to catch because:
There's a strong causal link between sleep-disordered breathing and attention deficits. If you've been diagnosed with ADHD and also have chronic fatigue or unrefreshing sleep, getting a proper sleep study is worth it.
In my case, the bottleneck has four components:
I've tried roughly everything. In ascending order of intervention:
Allergen control: frequent sheet washing, Mission Allergy encasements (has to be this brand according to my allergist and confirmed by my independent research — all the other ones are ineffective), HEPA filter, minimizing carpet/fabric surfaces. Necessary foundation but not sufficient alone.
Nasal sprays: Flonase → Azelastine → Dymista → Xhance → Allermi (custom compound: fluticasone + azelastine + oxymetazoline + ipratropium). Allermi has been the most effective at opening the nasal airway, but comes with concerns about rebound congestion from the oxymetazoline component. Been using Flonase for over 10 years now.
Allergy immunotherapy: subcutaneous allergy shots. A long play — takes years to fully work, but addresses the root allergic component, if it works. Unfortunately I didn't feel much benefit, if at all, from this.
Positional therapy: side sleeping (tennis ball trick, backpacks), elevated head of bed. Helps with gravity-dependent congestion and airway collapsibility.
External nasal support: Breathe Right strips, nasal dilators, nasal stents. Addresses the nasal valve component.
Things that didn't move the needle: Alaxo nasal stents, myofunctional therapy with an IOPI tongue trainer, inspiratory muscle training (Powerbreathe), and a homemade mandibular advancement device. All plausible in theory, none meaningfully changed my sleep quality.
PAP therapy: the gold standard. I started with CPAP (ResMed), saw maybe 10% improvement over 6 months. Switched to BiPAP (ResMed AirCurve) at 7 EPAP / 11 IPAP / 4 pressure support — about 30-40% improvement. Now on ASV (adaptive servo-ventilation), which dynamically adjusts pressure support breath-by-breath. ASV is the most sophisticated PAP machine — it targets not just obstruction but the variability in breathing effort itself. Still iterating.
After tens of thousands of dollars and hundreds of hours spent researching and experimenting, I feel at maybe 40%-50% of my pre-UARS baseline. Better than if I don't use my machine, which I do every once in a while for a week to ground myself, which is closer to 10% of my pre-UARS baseline. But still lots of work to do. I'm afraid there is probably some irreversible damage at this point, but I'm optimistic I can bring my 40% a lot higher as my sleep graphs still show lots of flow limitation and I still just feel tired and have the songs in my head. I hope to edit this post in the coming months with good news, as this is one of the main goals in my life today (besides growing Algoverse).
I wouldn't wish this condition on anyone. I often think about what my life would look like — career, happiness, everything — if I didn't have it. I'm grateful for everything I have and I'm not complaining. I got very lucky with a lot of things and could have been born in significantly worse circumstances. But it's hard not to wonder.
Almost everyone past a certain age should probably be on PAP therapy.
Snoring is way too normalized. When I was a kid, I could triangulate the sounds of my grandpa and my dad snoring loudly all night. My dad has an AHI of over 30 (that roughly equates to waking up every 2 minutes) and can take a nap after downing his second coffee of the day, but claims he doesn't feel any symptoms.
Those are extreme cases, but this happens at a lesser scale with everyone after a certain age. The airway degrades with age. Muscle tone decreases, soft tissue sags, the tongue falls back more easily. This isn't a disease process — it's normal aging. But the result is that most adults develop some degree of airway resistance during sleep, even if they never cross the clinical threshold for a sleep apnea diagnosis. The question isn't whether your airway narrows at night. It's how much, and whether the consequences are crossing the threshold into symptoms you'd notice.
The reason this matters: subclinical sleep-disordered breathing still fragments sleep architecture. You can have an AHI of 2 and still be losing deep sleep to subtle arousals that never get scored as events. PAP isn't just for people with a diagnosis — it's the single most effective intervention for sleep quality in anyone whose airway isn't perfectly patent at night. Which, past 30 or so, is most people.
One of the most useful conceptual models for understanding UARS treatment comes from u/carlvoncosel on Reddit, who has been writing about Work of Breathing (WOB) for years.
The core idea: UARS isn't just about whether your airway is open or closed. It's about how much effort your respiratory system expends to move air. Even if the airway never technically obstructs, increased resistance means your diaphragm and intercostal muscles have to work harder. This elevated WOB is itself the problem — it triggers arousals, fragments sleep, and drives the chronic fatigue and cognitive symptoms.
This reframing changes how you think about treatment. The goal of PAP therapy isn't just to prevent apneas or even hypopneas — it's to reduce the total work of breathing to a level where the respiratory effort is so low that the brain has no reason to arouse. This is why some UARS patients need BiPAP or even ASV despite having "normal" AHI numbers on CPAP: the CPAP might be keeping the airway open, but the patient is still fighting the expiratory pressure, which keeps WOB elevated.
BiPAP helps because the lower expiratory pressure (EPAP) reduces the work of breathing on exhale, while the higher inspiratory pressure (IPAP) provides a boost on inhale. The pressure support (IPAP minus EPAP) is essentially the machine doing part of the breathing work for you. The inhale/exhale ratio in OSCAR becomes a key metric: if it's close to 1:1, you're working too hard to exhale against the pressure. A healthy ratio is closer to 1:2.
carlvoncosel's key insight: stop thinking about events (apneas, hypopneas, RERAs) and start thinking about effort. The flow rate curve on OSCAR tells you everything — if it's not a clean sinewave, the work of breathing is elevated, regardless of what the event counters say.
Barry Krakow is one of the few sleep doctors who deeply understands UARS and treats it aggressively. His framework centers on what he calls "rounding the airway curve" — the idea that the goal of treatment is to progressively smooth out the flow rate waveform until it approximates a perfect sinewave.
In a healthy airway with no resistance, each breath produces a smooth, symmetrical curve: a clean rise on inhale, a clean fall on exhale. In UARS patients, the curve gets distorted. Common deformities include:
Krakow's treatment approach is iterative. You make a change — adjust EPAP, add pressure support, fix a leak, improve nasal breathing — then look at the curves again. Did they get smoother? Closer to a sinewave? If yes, you're on the right track. If not, iterate. The curves are the ground truth, not the event indices.
His other key principles: nasal breathing is a necessary precondition for PAP to work (you must solve nasal obstruction first), mouth leak is more damaging than most people realize, and the combination of a good nasal spray (like Allermi) + Breathe Right strip + properly titrated PAP is often the stack that finally works.
Krakow's approach is fundamentally empirical: try something, read the curves, iterate. He treats the flow rate waveform as the objective function and optimizes against it. This is why he's effective where most sleep doctors aren't — they're optimizing against AHI, which doesn't capture the signal that matters for UARS.
In my mental model, there are two archetypes of UARS patients — nasal obstruction (often due to allergies, like me), or jaw issues (recessed mandible and/or maxilla leading to a lack of airway space). Unfortunately in my case, it's both. It's causal — mouth breathing can lead to the latter.
Treating UARS is a high-dimensional optimization problem. Your variables include: EPAP, IPAP, pressure support, ramp time, EPR/flex settings, mask type, mask fit, nasal spray regimen, allergen control, sleep position, head elevation, mouth taping, humidity settings, and a dozen other knobs. Each one interacts with the others. Changing your EPAP might require changing your nasal spray. Fixing a leak might change your optimal pressure support. It's not a set of independent variables — it's a coupled system.
Since most sleep doctors are effectively useless for this problem, UARS patients need to take it upon themselves to solve it. You need to download open source software to analyze your sleep graphs yourself. The standard as of today is OSCAR.
The OSCAR data is worth diving into but it's very easy to delude yourself with spurious correlations from the flow rate graphs, leak graphs, event indices.
The best gradient signal in this case is how you feel when you wake up. That's it. Your morning vibes are the loss function. Did you wake up foggy or clear? Did you feel rested or wrecked? Ultimately, the ground truth is how your brain feels in the morning. You make a change, sleep on it, read the signal, and iterate. Some days the gradient is noisy. Some weeks you plateau. But over months, the trendline either moves or it doesn't.
Even if you have a doctor who knows UARS, this is why UARS treatment is still hard to outsource as of today. No one can feel your gradient signal for you. The best sleep doctors give you the framework, but you have to run the optimization loop yourself.
If you're on PAP therapy, you have to learn to read your own data in OSCAR. The key things to watch:
The Glasgow Index is a more granular metric than AHI for assessing residual flow limitation on PAP. It can filter by flow event type and analyze trends across multiple nights.
This is probably one of the most underdiagnosed conditions out there. If any of this sounds familiar — the fatigue, the fog, the "normal" sleep studies — it's worth pursuing.