For most people, sleeping without a pillow is not better. The exception is stomach sleepers, who may benefit from going flat because a pillow pushes the neck into an awkward angle. For back and side sleepers, removing the pillow creates a gap between the head and mattress that pulls the cervical spine out of its natural curve, often leading to neck pain and stiffness.
Why Stomach Sleepers May Benefit
Stomach sleeping already puts the spine in a compromised position. Most of your body weight sits in the midsection, which causes the lower back to sag. On top of that, your head has to turn to one side so you can breathe, extending the neck backward at an angle it isn’t designed to hold for hours. Adding a pillow lifts the head even higher and worsens that angle.
Sleeping without a pillow keeps the head closer to the mattress surface, reducing the degree of neck extension and rotation. This won’t fix every problem with stomach sleeping (it’s still the hardest position on the spine), but it removes one layer of strain. If you’re a committed stomach sleeper and wake up with neck soreness, ditching the pillow or switching to a very thin one is worth trying.
Why Back Sleepers Still Need One
When you lie on your back, your neck has a natural forward curve (called lordosis) that needs gentle support. Without a pillow, the head drops slightly backward, flattening that curve and creating tension in the muscles along the back of the neck. Over a full night, this can produce stiffness, headaches, or soreness that radiates into the upper shoulders.
A pillow of moderate thickness fills the small space between the back of your head and the mattress, keeping the spine in a neutral line from the base of the skull down through the tailbone. Too thick is just as problematic as too thin: a pillow that pushes your chin toward your chest creates the opposite misalignment. For back sleepers, the goal is a pillow that cradles the head without lifting it significantly.
Side Sleepers Have the Most to Lose
Side sleeping creates the largest gap between the head and the sleep surface. That gap is roughly the width of your shoulder, typically 4 to 6 inches. Without a pillow, the head drops sideways toward the mattress, bending the neck laterally and compressing the structures on one side while overstretching the other. This is a reliable recipe for morning neck pain and, over time, can contribute to chronic discomfort.
If you sleep on your side, pillow support isn’t optional. Orthopedic guidelines suggest measuring the distance from your shoulder to your ear while lying down and choosing a pillow that fills that space without forcing the head upward. Your mattress matters here too: a softer mattress lets your shoulder sink in deeper, reducing the gap and calling for a thinner pillow. A firmer mattress keeps the shoulder higher, so you need more loft to compensate. Larger-bodied people who sink further into a soft mattress may also need a lower pillow than someone with a smaller frame on the same bed.
Snoring and Sleep Apnea Get Worse Flat
Sleeping completely flat can worsen snoring and obstructive sleep apnea. When the head is level with the body, gravity pulls the tongue and soft tissues of the throat backward, narrowing the airway. Fluid also shifts toward the upper body during sleep, which can further constrict the pharynx.
A study published in Sleep & Breathing found that even a mild head elevation of 7.5 degrees significantly reduced the number of breathing interruptions per hour, dropping them from about 15.7 events to 10.7. Minimum blood oxygen levels also improved. The effect was strongest for people who slept on their backs, where the tongue is most likely to obstruct the airway. If you snore or have been told you stop breathing during sleep, removing your pillow would move you in the wrong direction. Slight elevation helps keep the airway open.
Acid Reflux Favors Elevation Too
People with gastroesophageal reflux (GERD) also do worse lying flat. When the head and upper body are level with the stomach, acid moves more easily into the esophagus. A systematic review of clinical trials found that elevating the head of the bed by about 20 centimeters (roughly 8 inches) led to meaningful improvements in reflux symptoms within six weeks. Participants who slept with elevation were more than twice as likely to report a significant reduction in symptom scores compared to those who slept flat.
A standard pillow alone doesn’t achieve this kind of elevation, since it only lifts the head rather than the entire upper body. But it does provide some angle. Going fully flat removes even that small advantage. If reflux is part of your life, a wedge pillow or blocks under the head of the bed are more effective than a regular pillow, and certainly better than no pillow at all.
Effects on Your Skin
One argument for going pillowless is that it reduces facial contact with fabric, which could theoretically help with breakouts and wrinkles. There’s some logic to this. Acne mechanica, a type of acne caused by friction, pressure, and trapped heat, develops when the face stays pressed against a surface for hours. Pillow fabric collects oil, sweat, bacteria, and skincare residue, then pushes it back into your pores. Stomach sleepers get the worst of it because the forehead and eye area bear the most compression, trapping heat and moisture.
But the skin benefits depend more on your sleep position than on whether you use a pillow. Back sleeping puts zero pressure on the face regardless of pillow use. Side sleeping compresses one cheek, which is why breakouts and sleep lines often appear unevenly. If skin concerns are motivating you, switching to back sleeping or using a silk pillowcase may be more practical than eliminating the pillow entirely. A 2024 clinical trial found that participants who switched to silk pillowcases reported 96 percent improved skin clarity and 90 percent fewer breakouts compared to cotton, likely because silk absorbs less oil and creates less friction.
Pillow Safety for Infants
For babies under one year old, the answer is unambiguous: no pillow. The American Academy of Pediatrics recommends keeping pillows, blankets, and all soft objects out of the sleep area for the entire first year of life. Soft bedding is the most common cause of accidental infant suffocation, and bed sharing with pillows or blankets increases the risk of sleep-related death by two to five times. Pillows can obstruct an infant’s airway or create spaces where a baby can become wedged. There is no safe pillow for an infant’s crib or bassinet.
How to Transition if You Want to Try
If you’re a stomach sleeper considering the switch, going cold turkey can feel strange after years of sleeping with a pillow. A gradual approach works better. Start by folding a thin towel and using it in place of your pillow for a few nights, then reduce the thickness over a week or two until you’re sleeping flat. Some people find it helpful to place a thin pillow under the hips instead, which can reduce lower back strain from stomach sleeping.
For everyone else, the better question isn’t whether to ditch the pillow but whether your current one is the right fit. A pillow that’s too old, too flat, or too thick for your sleep position causes many of the same problems people hope to solve by going without one. Replacing it with one that matches your sleeping position and body size is almost always more effective than removing it altogether.