The traditional approach to managing COMISA has focused on treating obstructive sleep apnea (OSA) and insomnia as separate entities, with OSA typically prioritized as the primary condition. However, emerging evidence underscores the bidirectional relationship between insomnia and OSA, where each condition can exacerbate or contribute to the development of the other. Management of COMISA is particularly challenging due to the variability in treatment responses, as insomnia symptoms are often associated with poor adherence to positive airway pressure (PAP) therapy. Furthermore, certain treatments for insomnia can aggravate OSA or related symptoms, such as excessive daytime sleepiness. Given this interplay, managing COMISA requires an integrated and multifaceted approach that addresses both conditions simultaneously.