No More Sleepless Nights: Dealing With Insomnia

There are different types of insomnia, most of which cause people to lie in bed awake, frustrated that they are unable to fall asleep or stay asleep. As a result, they toss and turn, and irritability increases. Insomnia can take various forms, including early morning arousal (difficulty staying asleep), sleeping latency (difficulty falling asleep), fragmented sleep (waking up multiple times during the night), and sleeping very lightly and waking feeling unrefreshed. Many people with insomnia want to avoid medication because they are concerned about potential addiction, or feeling spacey or drowsy the next day.

Insomnia can be categorized as:

• Acute—Usually periodic and goes away on its without treatment.
• Chronic—Occurring 3 or more nights per week for at least 3 months.

Finding the Causes of Insomnia

Sleep-wake cycles are dictated by internal circadian rhythms. These rhythms are strongly influenced by light entering through the eyes, which signals the brain to regulate production of certain hormones, including one called melatonin. Circumstances that unnaturally diminish the entrance of light into the eyes can disrupt the natural circadian rhythm, the production of necessary hormones, and therefore, an individual's proper sleep-wake cycle. Such circumstances include blindness and failing eyesight due to aging. Traveling to different time zones and jet lag, as well as working the night shift, disturb the natural circadian rhythm as well.

Insomnia can also be a sign of an underlying medical condition such as depression, an over-active thyroid, high blood pressure, heart disease, asthma, sleep apnea, restless leg syndrome, dementia, or pain disorders.

Several lifestyle factors can contribute to sleep disturbance. Keeping a sleep-wake diary is helpful in identifying and modifying these factors, which include:

• Use of stimulants, including caffeine, nicotine, and ingredients in common drugs, such as cold remedies and weight-loss medications. Some cause people to have difficulty falling asleep, others to wake up during the night.
• Alcohol use—While it may help you fall asleep, alcohol consumption is likely to produce interrupted sleep and is not recommended as an insomnia treatment.
• Working night or rotating shifts.
• Lack of regular exercise.
• Exercising too close to bedtime
• Eating too close to bedtime.
• Stress
• Excessive time on the computer or watching television.

Treating Insomnia With Lifestyle Changes

The most effective and frequently used conventional treatments to establish a restful sleep pattern may include a combination of approaches. These include achieving proper sleep hygiene, making other lifestyle alterations, and possibly medications.

Good sleep hygiene includes:

• Going to bed at the same time each night, even on your days off.
• Reserving your bed for sleep and sex.
• Watching television or reading in another room.
• Avoiding caffeine, alcohol, and cigarettes, especially in the afternoon and evening when it can interfere with sleep the most.
• Not laying in bed watching the clock. If you cannot fall asleep 15-20 minutes, get up and listen to calming music or read.
• Exercising often, but not too close to bedtime.
• Avoid naps if you can. If not, do so before 3 pm and nap for less than 30 minutes.
• Sleeping in a place with very little light and noise distraction.

If nothing seems to be working for you, there are treatment options available. These may include:

• Relaxation techniques—A multidisciplinary team, including medical doctors, specializing in sleep disturbances can train and guide people in such approaches as yoga, meditation, deep relaxation, biofeedback, hypnosis, massage, and/or guided imagery. Practicing one of these techniques within 30 minutes of bedtime may be helpful. Simple changes in bedtime routine may also be effective. These include taking a warm bath, listening to soothing music, and drinking warm milk.
• Acupuncture—Positive effects of the use of this ancient Chinese practice have been shown however, more proof is needed before it can be recommended as an effective treatment for insomnia. A typical protocol is to receive acupuncture treatments weekly until a normal sleep pattern is achieved, followed by maintenance sessions. However, a licensed and certified acupuncturist will determine the most appropriate treatment regimen for each individual.
• Bright light therapy—A box emits bright light similar to outdoor light. Using the light box daily may help regulate your body's circadian rhythm. The effectiveness of this treatment is undetermined.
• Cognitive therapy—This behavioral method involves addressing misconceptions and unrealistic expectations about both insomnia and the nature of sleep. Some issues addressed during cognitive therapy include napping to compensate for poor sleep at night, anxiety about bedtime, fear of sleeplessness, beliefs about necessary hours of sleep, and attributing insomnia to age, ability to sleep, and/ or possible chemical imbalance.

Treating Insomnia with Prescription Sleep Medications

Long-term use of sleeping pills is not recommended, as dependence is possible with some classes of drugs. Research on safety and effectiveness is ongoing. For temporary relief of insomnia, the following medications offer a solution:

• Non-benzodiazepine sedatives—Short-acting sedative-hypnotics, such as zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta).
• Melatonin receptor agonists (unrelated to melatonin supplement)—An example of this medication is ramelteon (Rozerem).
• Benzodiazepines—Hypnotics, such as nitrazepam, temazepam (Restoril), and lorazepam (Ativan).

The National Sleep Foundation recommends that people taking sleep medications begin with the lowest possible dose that is effective, use the drugs on a short-term basis, and take the drugs intermittently if they are using them on a long-term basis.

Treating Insomnia With Herbs and Supplements

While some cultures have a long history of using supplements and herbal remedies for the treatment of insomnia, such practices have only gained popularity over the last few decades in the US and other Western nations. Check with your doctor before trying herbs or supplements to make sure they are safe. Some have serious side effects and others may mix poorly with medication you are already taking. Although herbal remedies may be helpful for some people, most scientific studies have been unable to prove them effective in treating insomnia. Some that may hold promise are:

• Valerian root
• Lavender flower
• Lemon balm
• Passion flower
• Chamomile flower
• Hops
• Orange peel

Treating Insomnia with Melatonin

This neurotransmitter is secreted by the pineal gland and it regulates the sleep cycle. Melatonin is secreted at night, and the secretion is suppressed by bright light during the day. When melatonin secretion is not synchronized with the light-dark cycle, sleep disturbances occur. Frequently touted as a valuable supplement for insomnia, melatonin has shown only mixed results for insomnia in studies.

Melatonin may be useful for temporary sleep disturbances from a change in schedule (daytime work to nighttime) or sudden disruption of the circadian rhythm as with jet lag. Speak with your doctor if you would like to try it, particularly because there are certain circumstances in which it should not be used until more information is available. These may include pregnancy, breastfeeding, autoimmune disorders, leukemia, and lymphoma.

Substances to Avoid

In addition to caffeine, excessive alcohol, and particular medications, certain herbs sold over the counter can induce wakefulness. These include ginseng, ephedra, yohimbe, and cola nut. The hormonal supplement DHEA may also contribute to insomnia.

Putting Insomnia to Rest

Insomnia is a common problem that results not only in personal frustration and discomfort, but also is associated with decreased work performance, lost productivity, accidents, and hospitalization. Treatment for insomnia must be specific to the individual to achieve optimal results. Prescription medications may be used to achieve short-term results. However, nonprescription treatments are commonly recommended, inexpensive, and effective. Talk with your doctor about different strategies that may be combined to help you find relief from insomnia.

Revision Information

• Reviewer: Michael Woods, MD, FAAP
• Review Date: 02/2017
• Update Date: 02/01/2017