Insomnia

1 What is Insomnia?

Insomnia comes from the Latin words for “no sleep.” Insomnia is characterized by:

  • Difficulty falling asleep
  • Difficulty staying asleep
  • Waking up too early
  • Poor quality ("non-restorative") sleep

Insomnia may be primary or secondary:

  • Primary insomnia means that the inability to sleep is not caused by other health problems.
  • Secondary insomnia is due to other health conditions that interfere with sleep. It is also called “comorbid insomnia.”

Duration of Insomnia

Insomnia is often categorized by how long it lasts:

  • Transient insomnia lasts for a few days.
  • Short-term insomnia lasts for no more than 3 weeks.
  • Chronic insomnia occurs at least 3 nights per week for 1 month or longer.

2 Symptoms

The main symptom of insomnia is trouble falling or staying asleep, which leads to lack of sleep. If you have insomnia, you may:

InsomniaSymptoms

  • Lie awake for a long time before you fall asleep
  • Sleep for only short periods
  • Be awake for much of the night
  • Feel as if you haven't slept at all
  • Wake up too early

The lack of sleep can cause other symptoms. You may wake up feeling tired or not well-rested, and you may feel tired during the day. You also may have trouble focusing on tasks. Insomnia can cause you to feel anxious, depressed, or irritable.

Insomnia also can affect your daily activities and cause serious problems. For example, you may feel drowsy while driving. Driver sleepiness (not related to alcohol) is responsible for almost 20 percent of all serious car crash injuries. Research also shows that insomnia raises older women’s risk of falling.

If insomnia is affecting your daily activities, talk with your doctor. Treatment may help you avoid symptoms and problems related to the disorder. Also, poor sleep may be a sign of other health problems. Finding and treating those problems could improve your overall health and sleep.

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3 Causes

A reaction to change or stress is a common cause of short-term and transient insomnia. This condition is sometimes referred to as adjustment sleep disorder.

The trigger could be a major or traumatic event such as:

  • An acute illness
  • Injury or surgery
  • The loss of a loved one
  • Job loss

Temporary insomnia can also develop after a relatively minor event, including:

  • Extremes in weather
  • An exam
  • Traveling, particularly across time zones
  • Trouble at work

In most cases, normal sleep almost always returns when the condition resolves, the individual recovers from the event, or the person becomes used to the new situation.

Treatment is needed if sleepiness interferes with functioning or if it continues for more than a few weeks. Individual responses to stress vary and some people may not experience insomnia at all, even during very stressful situations while others may suffer from insomnia in response to very mild stressors.

Female Hormonal Fluctuations:

Fluctuations in female hormones play a major role in insomnia in women over their lifetimes. This insomnia is usually temporary.

  • During Menstruation. Progesterone promotes sleep, and levels of this hormone plunge during menstruation, causing insomnia. (When they rise during ovulation, women may become sleepier than usual.)
  • During Pregnancy. The effects of changes in progesterone levels in the first and last trimester can disrupt normal sleep patterns.
  • Menopause. Insomnia can be a major problem during the transition to menopause (perimenopause), when hormones are fluctuating intensely. Insomnia during this period may be due to several different factors. In some women, hot flashes, sweating, and a sense of anxiety can disrupt sleep and cause sudden and frequent awakening. In many cases, the insomnia is temporary. Treating hot flashes may help resolve chronic insomnia.

Jet Lag:

Air travel across time zones often causes insomnia. After long plane trips, a day of adjustment is usually needed for each time zone crossed. Traveling from the east to an earlier time zone in the west seems to be less disruptive than traveling to a later time zone in the east because it is easier to lengthen a circadian phase than to shorten it.

Effect of Light and Other Environmental Disruptions:

Light, noise, and uncomfortable temperatures can cause sleeplessness. Depending on the time of day, too much or too little light can disrupt sleep.

  • Excessive Light at Night. A person's biologic circadian clock is triggered by sunlight, and very bright artificial light maintains wakefulness.
  • Insufficient Light during the Day. Insufficient exposure to light during the day, as occurs in some disabled elderly patients who rarely venture outside, may also be linked with sleep disturbances.

Other Causes of Short-Term or Transient Insomnia:

  • Caffeine: Caffeine is a stimulant, which can interfere with falling asleep.
  • Nicotine: Nicotine is also a stimulant, but quitting smoking can lead to transient insomnia.
  • Partner's Sleep Habits: A partner’s sleep habits, including snoring, can impair one’s own sleep.
  • Medications: Insomnia is a side effect of many common medications, including over-the-counter preparations that contain caffeine or decongestants. If you suspect your medications are causing you to lose sleep, check with your doctor or pharmacist.

Causes of Chronic Insomnia:

Sleep problems seem to run in families. Many people with insomnia have a family history of insomnia, with the mother being the most commonly affected family member. Still, because so many factors are involved in insomnia, a genetic component is difficult to define.

Anxiety, Depression, and Other Mental Health Disorders:

Many cases of chronic insomnia cases have an emotional or psychological basis. The disorders that most often cause insomnia are:

  • Anxiety
  • Depression
  • Bipolar disorder
  • Attention-deficit hyperactivity disorder
  • Post-traumatic stress disorder

Insomnia may also cause emotional and mental health problems, such as depression and anxiety. It is often unclear which condition has triggered the other, or if the two conditions, in fact, have a common source.

Psycho physiologic Insomnia:

In many cases, it is unclear if chronic insomnia is a symptom of some physical or psychological condition or if it is a primary disorder of its own. In most instances, a mix of psychological and physical conditions causes the insomnia.

Psycho physiologic insomnia occurs when:

  • Transient insomnia disrupts the person's circadian rhythm.
  • The patient begins to associate the bed not with rest and relaxation but with a struggle to sleep. A pattern of sleep failure emerges.
  • Over time, this event repeats, and bedtime becomes a source of anxiety. Once in bed, the patient broods over the inability to sleep, the consequences of sleep loss, and the lack of mental control. All attempts to sleep fail.
  • Eventually excessive worry about sleep loss becomes persistent and provides an automatic nightly trigger for anxiety and arousal. Unsuccessful attempts to control thoughts, images, and emotions only worsen the situation. After such a cycle is established, insomnia becomes a self-fulfilling prophecy that can persist indefinitely.

Medical Conditions and Their Treatments:

Among the many medical problems that can cause chronic insomnia are allergies, benign prostatic hyperplasia (BPH), arthritis, gastroesophageal reflux disease (GERD), asthma, chronic obstructive pulmonary disorder (COPD), rheumatologic conditions, Alzheimer's disease, Parkinson's disease, hyperthyroidism, epilepsy, and fibromyalgia. Other types of sleep disorders, such as restless legs syndrome and sleep apnea, can cause insomnia. Many patients with chronic pain also sleep poorly.

Medications:

Among the many medications that can cause insomnia are antidepressants (fluoxetine, bupropion), theophylline, lamotrigine, felbamate, beta-blockers, and beta-agonists.

Substance Abuse:

Substance abuse can cause chronic insomnia. This is especially true for alcohol, cocaine, and sedatives. One or two alcoholic drinks may help reduce stress and initiate sleep. However, excessive alcohol use tends to fragment sleep and cause wakefulness a few hours later. It also increases the risk for other sleep disorders, including sleep apnea and restless legs. Alcoholics often suffer insomnia during withdrawal and, in some cases, for several years during recovery.

4 Making a Diagnosis

Your doctor will likely diagnose insomnia based on your medical and sleep histories and a physical exam. He or she also may recommend a sleep study. For example, you may have a sleep study if the cause of your insomnia is unclear.

Medical History

To find out what's causing your insomnia, your doctor may ask whether you:

  • Have any new or ongoing health problems
  • Have painful injuries or health conditions, such as arthritis
  • Take any medicines, either over-the-counter or prescription
  • Have symptoms or a history of depression, anxiety, or psychosis
  • Are coping with highly stressful life events, such as divorce or death

Your doctor also may ask questions about your work and leisure habits. For example, he or she may ask about your work and exercise routines; your use of caffeine, tobacco, and alcohol; and your long-distance travel history. Your answers can give clues about what's causing your insomnia.

Your doctor also may ask whether you have any new or ongoing work or personal problems or other stresses in your life. Also, he or she may ask whether you have other family members who have sleep problems.

Sleep History

To get a better sense of your sleep problem, your doctor will ask you for details about your sleep habits. Before your visit, think about how to describe your problems, including:

  • How often you have trouble sleeping and how long you've had the problem
  • When you go to bed and get up on workdays and days off
  • How long it takes you to fall asleep, how often you wake up at night, and how long it takes to fall back asleep
  • Whether you snore loudly and often or wake up gasping or feeling out of breath
  • How refreshed you feel when you wake up, and how tired you feel during the day
  • How often you doze off or have trouble staying awake during routine tasks, especially driving

To find out what's causing or worsening your insomnia, your doctor also may ask you:

  • Whether you worry about falling asleep, staying asleep, or getting enough sleep
  • What you eat or drink, and whether you take medicines before going to bed
  • What routine you follow before going to bed
  • What the noise level, lighting, and temperature are like where you sleep
  • What distractions, such as a TV or computer, are in your bedroom

To help your doctor, consider keeping a sleep diary for 1 or 2 weeks. Write down when you go to sleep, wake up, and take naps. (For example, you might note: Went to bed at 10 p.m.; woke up at 3 a.m. and couldn't fall back asleep; napped after work for 2 hours.)

Also write down how much you sleep each night, as well as how sleepy you feel throughout the day.

Physical Exam

Your doctor will do a physical exam to rule out other medical problems that might cause insomnia. You also may need blood tests to check for thyroid problems or other conditions that can cause sleep problems.

Sleep Study

Your doctor may recommend a sleep study called a polysomnogram (PSG) if he or she thinks an underlying sleep disorder is causing your insomnia.

You’ll likely stay overnight at a sleep center for this study. The PSG records brain activity, eye movements, heart rate, and blood pressure.

A PSG also records the amount of oxygen in your blood, how much air is moving through your nose while you breathe, snoring, and chest movements. The chest movements show whether you're making an effort to breathe.

5 Treatment

The American Academy of Sleep Medicine (AASM) recommends a number of behavioral methods and prescription medications as the main treatments for insomnia. According to the AASM, these treatment options can improve both quality and quantity of sleep for people with insomnia.

Doctors agree that behavioral therapies should be the first-line treatment for insomnia. For children in particular, medications should rarely be used as initial treatment.

Various approaches are available to help people learn how to relax and sleep well. Behavioral techniques can actually cure chronic insomnia in many cases, and studies report that they help nearly all patients with primary chronic insomnia. The benefits of psychological and behavioral therapy in managing insomnia are long lasting.

Although medications can help people with insomnia to sleep, they cannot cure the condition. In addition, behavioral methods act faster. Behavioral methods work for all age groups, including children and elderly patients.

Behavioral methods include:

  • Stimulus control
  • Cognitive behavioral therapy
  • Relaxation training and biofeedback
  • Sleep restriction

All behavioral approaches have the same basic goals:

  • To reduce the time it takes to go to sleep to below 30 minutes
  • To reduce wake-up periods during the night

Stimulus Control:

Stimulus control is considered the standard treatment for primary chronic insomnia and may also be helpful for some patients with secondary insomnia. The primary goal of stimulus control is to regain the idea that the bed is for sleeping. It involves the following:

  • Go to bed only when ready to sleep or for sex.
  • If unable to sleep within 15 - 20 minutes, get up and go into another room. (People who find it physically difficult to get out of bed should sit up and do something relatively arousing, like reading a book.)
  • Maintain a regular wake-up time no matter how few hours you actually sleep.
  • Avoid naps.

Cognitive-Behavioral Therapy: Cognitive behavioral therapy (CBT) is a form of therapy that emphasizes observing and changing negative thoughts about sleep such as, "I'll never fall asleep." It uses actions intended to change behavior.

The goal is to change or correct misconceptions about the ability to fall and stay asleep. Emphasis is on reinforcing the need for 7 - 8 hours of sleep each night and addressing the anxiety that patients with insomnia often develop around sleep. Many studies have shown it to work as well or better than drugs. 

Relaxation Training and Biofeedback: Relaxation training includes breathing and guided imagery techniques. Progressive muscle relaxation is another technique for inducing sleep that works well for many people. It takes about 10 minutes to perform:

  • Focus on one specific muscle group at a time. Most people start with the muscles in one foot. Inhale and tense the foot muscles for about 8 seconds. (Do this gently. It is not intended to cause severe pain or muscle contractions.)
  • Relax the foot, and let it become loose and limp. Stays relaxed for 15 seconds, and then repeat with the other foot.
  • Move up to the next muscle group and repeat the sequence, doing one side of the body at a time. Move progressively from each foot and leg up through the abdomen and chest, to each hand and arm, then to the neck, shoulders, and face.

Biofeedback may be combined with relaxation techniques. Biofeedback involves being monitored with an electroencephalogram (EEG), a device that measures brain waves. Patients are given feedback to recognize certain states of tension or sleep stages so that they can either avoid or repeat them voluntarily.

Paradoxical Intention and Sleep Restriction Therapies: Paradoxical intention is a type of cognitive technique that aims to conquer anxiety about insomnia by forcing the patient to stay awake. Not trying to fall asleep may help relieve performance anxiety associated with sleep.

Sleep restriction therapy is similar to paradoxical intention. It involves limiting the time spent in bed to the number of hours that are typically actually spent asleep. Eventually the sleep loss helps some people fall asleep faster and spend more time asleep. As sleep improves, the hours spent in bed are increased.

Drug Therapy:

  • In general, the following considerations are important regarding the use of medications for the treatment of insomnia:
  • Underlying mental health problems, such as anxiety or depression, should be addressed first.
  • Behavioral or psychological techniques can actually correct insomnia, while prolonged use of sleeping pills can only produce temporary improvement.
  • Non-benzodiazepine sedative hypnotics may be better tolerated than benzodiazepines and have less risk of dependency. However, these drugs may cause hazardous or strange behaviors, such as driving, making phone calls, or eating while asleep. If you need to take one of these prescription drugs, start with as low a dose as possible.
  • For adults over age 60 years, studies suggest that the risks of sedative hypnotics may far outweigh their benefits. Sleep medications increase the risks for falls, depression, and memory loss in older patients. Elderly patients should generally start sleep medications at lower doses than younger patients.
  • As a general rule, do not take either prescription nor non-prescription sleeping pills on consecutive days or for more than 2 - 4 days a week.
  • If insomnia is still a problem after stopping the drug and continuing with good sleep hygiene, this pattern can be repeated again, but for only up to 4 weeks.
  • Medication should be withdrawn gradually, and the patient should be aware of the possibility of rebound insomnia after stopping medication. Rebound insomnia is the return of insomnia after medication is discontinued. It usually lasts for several days and can be more severe than the original insomnia.
  • Alcohol intensifies the side effects of all sleeping medication and should be avoided.
  • If chronic insomnia is accompanied by depression or anxiety, treating these problems first may be the best approach.

Medications:

Many older Americans use some form of sleep aid pill, including prescription or over-the-counter drugs. Over-the-counter (nonprescription) medications make use of the drowsiness caused by some common medications. Prescription drugs used specifically for improving sleeping are called sedative hypnotics. These drugs include benzodiazepines and non-benzodiazepines.

Sedative hypnotics carry risks for dependence, tolerance, and rebound insomnia:

  • Dependence means relying on a drug for falling asleep and having difficulty falling asleep or achieving restful sleep without it.
  • Tolerance is being unable to fall asleep using the original dose and needing to take progressively higher doses of medication.
  • Rebound insomnia can occur after a patient stops taking the drug. It typically causes 1 - 2 nights of sleep disturbance, daytime sleepiness, and anxiety. In some cases, patients may experience a temporary worsening of long-term insomnia.

Common Non-Prescription Sleep Medications:

Brands with Antihistamines: Many over-the-counter sleeping medications use antihistamines, which cause drowsiness. Diphenhydramine (Benadryl, generic) is the most common antihistamine used in non-prescription sleep aids.

Some drugs marketed as sleep aids contain diphenhydramine alone, while others contain combinations of diphenhydramine with pain relievers (such as Tylenol PM and its generic forms). Doxylamine (Unison, generic) is another antihistamine used in sleep medications.

Certain antihistamines indicated only for allergies, such as chlorpheniramine (Chlor-Trimeton, generic) or hydroxyzine (Atarax, Vistaril, generic) may also be used as mild sleep-inducers.

Unfortunately, most of these drugs leave patients feeling drowsy the next day and may not be very effective in providing restful sleep. Side effects include:

  • Daytime sleepiness
  • Cognitive impairment
  • Dizziness
  • Drunken movements
  • Blurred vision
  • Dry mouth and throat

In general, people with angina, heart arrhythmias, glaucoma, or problems urinating should avoid these drugs. They should not be used at the same time as medications that prevent nausea or motion sickness. Patients with chronic lung disease should also avoid some non-prescription sleeping aids, such as those containing doxylamine.

Common Pain Relievers:

When sleeplessness is caused by minor pain, simply taking acetaminophen (Tylenol, generic) or a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen (Advil, Motrin, generic), can be very helpful without causing any daytime sleepiness.

Non-Benzodiazepine Hypnotics:

Newer short-acting non-benzodiazepines can induce sleep with fewer side effects than benzodiazepines. Both benzodiazepine and non-benzodiazepine sedative hypnotics act on gamma-aminobutyric acid (GABA) receptor sites in the brain, but non-benzodiazepines are more specific in the subunits they target.

These drugs are now the preferred sedative hypnotic drugs for the treatment of insomnia. In general, non-benzodiazepine hypnotics are recommended for short-term use (7 - 10 days), and treatment should not exceed 4 weeks.

Brands: Non-benzodiazepine hypnotics currently approved in the United States are:

  • Zolpidem (Ambien, Ambien CR, generic) is one of the most commonly prescribed drugs for insomnia. It lasts longer than zaleplon. Patients should not take it unless they plan on getting at least 7 - 8 hours of sleep. A lower-dose, sublingual (under-the-tongue) formulation of zolpidem (Intermezzo) is approved for patients who wake up abruptly in the middle of the night and have trouble falling back asleep. Patients take it as needed when they awaken in the night (but must be able to get at least 4 hours of sleep after taking.
  • Zaleplon (Sonata, generic) is the shortest-acting hypnotic available. Because it is rapidly eliminated from the body it may be best for people who have difficulty falling asleep, not those who wake up often throughout the night. The drug takes effect within 30 minutes and may be taken at bedtime or later as long as the patient can sleep for at least 4 hours.
  • Eszopiclone (Lunesta) may help improve both sleep maintenance and daytime alertness. Eszopiclone is related to zopiclone (Imovane), which has been used for many years in Europe. Unlike other sleep medications, eszopiclone was the first sleep medication approved to be taken on a long-term basis.
  • Ramelteon (Rozerem) is the newest type of sedative hypnotic but it is not technically a non-benzodiazepine hypnotic. Unlike other prescription sleep drugs, which target GABA receptors, ramelteon works by targeting melatonin receptors. Ramelteon is not habit forming and is the first sleep drug not designated as a controlled substance.

Side Effects:

All of these drugs have fewer morning side effects than the benzodiazepines, including morning sedation and memory loss (although they can occur to some degree). When patients first start taking any of these drugs, they should use caution during morning activities until they are sure how the drug affects them.

General side effects may include:

All non-benzodiazepine drugs carry labels warning that that these drugs can cause sleep-related behavior, including driving, making phone calls, and preparing and eating food while asleep. (Most cases of sleepwalking and sleep driving likely occur when patients use zolpidem along with alcohol or other drugs or take more than the recommended dose.)

In addition, severe allergic reactions (anaphylaxis) and facial swelling (angioedema) can occur even the first time one of these drugs is taken.

For zolpidem, patients should:

  • Take zolpidem immediately before going to sleep
  • Take zolpidem only when able to get a full night’s sleep (7 - 8 hours)
  • Not drink alcohol the same evening
  • Not take more than the prescribed dose
  • Use caution in the morning when getting out of bed, driving, or operating heavy machinery

Interactions:

As with any hypnotics, alcohol increases the sedative effects of these drugs. These hypnotics also interact with other drugs, including rifampin, ketoconazole, erythromycin, and cimetidine. They may also interfere with or be interfered by other drugs. Patients should report all medications to their doctors.

Rebound Insomnia, Dependence, and Tolerance: The risk for rebound insomnia, dependence, and tolerance is lower with non-benzodiazepine hypnotics than with benzodiazepine drugs. These drugs are still subject to abuse. In any case, no hypnotic should be taken for more than 7 - 10 days or at higher than the recommended dose without a doctor's approval.

Benzodiazepine Hypnotics:

Benzodiazepines used to be the most commonly prescribed sedative hypnotics.

Brands: Commonly prescribed benzodiazepines:

  • Long-acting benzodiazepines include flurazepam (Dalmane, generic), clonazepam (Klonopin, generic), and quazepam (Doral).
  • Medium- to short-acting benzodiazepines include triazolam (Halcion), lorazepam (Ativan), alprazolam (Xanax), temazepam (Restoril), oxazepam (Serax), and estazolam (ProSom), which are all available as generics. Short-acting benzodiazepines may be useful for air travelers who want to reduce the effects of jet lag.

Side Effects:

Elderly people are more susceptible to side effects and should usually start at half the dose prescribed for younger people. They should not take long-acting forms.

Side effects may differ depending on whether the benzodiazepine is long or shorting acting. They include:

  • Severe allergic reactions, including facial swelling, can occur even with the first use of a benzodiazepine drug.
  • Respiratory problems may occur with overuse or in people with pre-existing respiratory illness
  • The drugs may increase depression, a common co-condition in many people with insomnia.
  • Respiratory depression (abnormally slow and shallow breathing) may occur with overuse or with people with pre-existing respiratory illness.
  • Long-acting drugs have a very high rate of residual daytime drowsiness compared to other types of sleeping pills. They have been associated with a significantly increased risk for automobile accidents and falls in the elderly, particularly in the first week after taking them. Shorter-acting benzodiazepines do not appear to pose as high a risk.
  • Memory loss, sleepwalking, sleep driving, eating while asleep, and other odd mood states may occur. These effects are enhanced by alcohol.
  • Urinary incontinence may occur, particularly in older patients and when taking long-acting formulations.
  • Because these drugs cross the placenta and enter breast milk, pregnant women or nursing mothers should not use them. Benzodiazepine use in the first trimester of pregnancy may be associated with the development of cleft lip in newborns.
  • In rare cases, overdoses can be fatal.

Interactions:

Benzodiazepines are potentially dangerous when combined with alcohol. Some medications, like the ulcer medication cimetidine, can slow the metabolism of the benzodiazepine.

Withdrawal Symptoms:

Withdrawal symptoms usually occur after prolonged use and indicate dependence. They can last 1 - 3 weeks after stopping the drug and may include:

  • Gastrointestinal distress
  • Sweating
  • Disturbed heart rhythm
  • In severe cases, patients might hallucinate or experience seizures, even a week or more after the drug has been stopped.
  • The chances for rebound insomnia are higher with the short-acting benzodiazepines than with the longer-acting ones.

Antidepressants:

Antidepressants are sometimes used to treat insomnia that may be caused by depression (secondary insomnia). In addition, certain types of antidepressants with sedating properties are prescribed for the treatment of primary insomnia, generally in lower doses than used to treat depression.

6 Prevention

Insomnia can often be prevented if you identify and deal with problems that could cause or exacerbate insomnia, such as;

  • underlying medical problems, like depression,
  • behaviors such as caffeine consumption.

However, when treatment of medical or behavioral factors does not improve the insomnia or when there is no apparent underlying cause (as in primary insomnia), your doctor may recommend other treatment methods.

Home treatment to prevent insomnia.

  • Many sleep problems can be overcome by simple, common-sense measures:
  • Cut down on late-night snacks and late-evening heavy dinners. Some experts recommend that you should not eat at least three hours before bedtime. Protein promotes alertness and carbohydrates calm and drowsiness, so eat a light, high-protein, low-carbohydrate lunch. This will decrease early afternoon drowsiness, and make an afternoon nap less tempting. Conversely, a high-carbohydrate, low-protein supper should help encourage sleepiness closer to bedtime.
  • Exercise - even moderate exercise helps control stress and releases natural stimulants, decreasing the need for external stimulants such as caffeine. An exercise routine should help regulate your sleep cycles and make you feel sleepier in the late evening. However, avoid exercising vigorously too close to bedtime.
  • Don't use your bedroom, even less your bed, as a place for activities other than sleep and intimacy. Get into bed when you are ready to sleep and leave it when you wake, to avoid sending your body conflicting cues about sleep and waking life. If you wake up in the middle of the night and can't fall asleep within half an hour, get up and rest or read in a comfortable chair until you become sleepy. Establish a bedtime ritual of cues for going to sleep. These could include having a bath or drinking a glass of warm milk (milk contains an amino acid that is converted into a sleep-enhancing compound in the brain). Many people feel relaxed after sex. Relaxation techniques may also be useful.
  • Cut down on daytime napping if it starts to affect your regular sleep patterns. Avoid napping within seven or eight hours of bedtime.
  • Avoid alcohol in the late evening.
  • If your insomnia persists, keep a diary of your sleep history. This may be helpful later in diagnosing an underlying cause.

7 Alternative and Homeopathic Remedies

More than 1.5 million Americans use complementary and alternative remedies for insomnia. Many people choose herbal and dietary supplement remedies. (Valerian and melatonin are among the most popular alternative remedies for insomnia.) Some, such as chamomile tea or lemon balm, are generally harmless for most people. Others have more serious side effects and interactions.

The American Academy of Sleep Medicine (AASM) advises that there is only limited scientific evidence to show that herbal and dietary supplements are effective sleep aids. The AASM recommends that these products should be taken only if approved by a doctor. Be sure to talk to your doctor if you are considering taking any herbal or dietary supplement. Some of these products can interact with prescription medications.

Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Patients should always check with their doctors before using any herbal remedies or dietary supplements.

Melatonin: Melatonin is the most studied dietary supplement for insomnia. It appears to reduce the time to fall asleep (sleep onset) and the time spent asleep (sleep duration). However, there are no consistent standards on melatonin doses. Some research suggests that 0.3 mg may be the most effective dosage in many people with insomnia. However, higher doses may keep some people awake and may also cause mental impairment, severe headaches, and nightmares. Although melatonin may not have many benefits for most people with chronic insomnia, studies suggest that it may help travelers with jet lag and people with delayed sleep syndrome.

Valerian root: Valerian is an herb that has sedative qualities and is commonly used by people with insomnia. Some studies have indicated that it may help improve the quality of sleep, but there have been few rigorous and well-conducted trials to prove it is effective.

Kava: Kava has been used to relieve anxiety and improve sleep. It is dangerous. There have been reports of liver failure and death from this herb, with highest risk in those with liver disease. Kava can interact dangerously with certain medications, including alprazolam, an anti-anxiety drug. Kava also increases the strength of certain other drugs, including other sleep medications, alcohol, and antidepressants. Do not use this herb.

Tryptophan and 5-L-5-hydroxytryptophan (HTP): Tryptophan is an amino acid used in the formation of the neurotransmitter serotonin, which is associated with healthy sleep. L-tryptophan used to be marketed for insomnia and other disorders but was withdrawn after contaminated batches caused a rare but serious and even fatal disorder called eosinophilia myalgia syndrome. 5-HTP, a byproduct of tryptophan, is still available as a supplement. There is little evidence that 5-HTP relieves insomnia.

8 Lifestyle and Coping

DealwithInsomnia

Lifestyle modifications are necessary in order to cope with insomnia.

Proper sleep hygiene should accompany any behavioral method. The term sleep hygiene is used to describe simple behaviors that may help everyone improve their sleep. These include:

  • Establish a regular time for going to bed and getting up in the morning. Stick to this schedule even on weekends and during vacations.
  • Use the bed for sleep and sexual relations only, not for reading, watching television, or working. Excessive time in bed disrupts sleep.
  • Avoid naps, especially in the evening.
  • Exercise before dinner. A low point in energy occurs a few hours after exercise; sleep will then come more easily. Exercising close to bedtime, however, may increase alertness.
  • Taking a hot bath about 1.5 - 2 hours before bedtime may help you fall asleep more easily. (Taking a bath just before bed may increase alertness.)
  • Do something quiet and relaxing in the 30 minutes before bedtime. Reading, meditating, or a leisurely walk are all appropriate activities.
  • Keep the bedroom relatively cool and well ventilated.
  • Do not look at the clock. Obsessing over time will just make it more difficult to sleep.
  • Eat light meals, and schedule dinner 4 - 5 hours before bedtime. A light snack before bedtime can help sleep, but a large meal may have the opposite effect.
  • Spend at least a half hour in daylight every day. The best time is early in the day.
  • Avoid fluids just before bedtime so that sleep is not disturbed by the need to urinate.
  • Avoid stimulants such as caffeine or nicotine in the hours before sleep.
  • Avoid alcohol in the hours before bedtime. While alcohol may help you fall asleep quickly, it can cause you to awaken in the middle of the night.
  • If still awake after 15 - 20 minutes, go into another room, read or do a quiet activity using dim lighting until feeling very sleepy. (Don't watch television or use bright lights.)
  • If distracted by a sleeping bed partner, moving to the couch or a spare bed for a couple of nights might be helpful.
  • If a specific worry is keeping you awake, thinking of the problem in terms of images rather than in words may help you to fall asleep more quickly and to wake up with less anxiety.

9 Risks and Complications

There are several risks and complications associated with insomnia.

Insomnia itself is not life threatening, but it can increase the risk of accidents, psychiatric problems, and certain medical conditions, affect school and work performance, and significantly interfere with quality of life. Lack of sleep can cause weight gain and obesity.

Increased Risk of Accidents:

Sleepiness increases the risk for motor vehicle accidents. Studies indicate that drowsy driving is as risky as drunk driving.

Quality of Life:

Surveys show that people with severe insomnia have a quality of life that is almost as poor as those who have chronic medical conditions, such as heart failure. Daytime sleepiness can lead to decreased energy, irritability, mistakes at work and school, and poorer relationships.

Thinking and Performance:

Insomnia makes it harder to concentrate and perform tasks. Deep sleep deprivation impairs the brain's ability to process information and reduces concentration.

Mood Disorders:

Although stress and depression are major causes of insomnia, insomnia may also increase the activity of the hormones and pathways in the brain that are associated with mental health problems. Chronic insomnia may increase the risk of developing depression and anxiety.

Even modest alterations in waking and sleeping patterns can have significant effects on a person's mood. In both children and adults, the combination of insomnia and daytime sleepiness can produce more severe depression than either condition alone.

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