Definition of Insomnia
Insomnia is a persistent disorder that can make it hard to fall asleep, hard to stay asleep or both, despite the opportunity for adequate sleep. With insomnia, you usually awaken feeling unrefreshed, which takes a toll on your ability to function during the day. Insomnia can sap not only your energy level and mood but also your health, work performance and quality of life.
How much sleep is enough varies from person to person. Most adults need seven to eight hours a night.
Many adults experience insomnia at some point, but some people have long-term (chronic) insomnia. Insomnia may be the primary problem, or it may be secondary due to other causes, such as a disease or medication.
You don’t have to put up with sleepless nights. Simple changes in your daily habits can often help.
Symptoms of Insomnia
Insomnia symptoms may include:
- Difficulty falling asleep at night
- Awakening during the night
- Awakening too early
- Not feeling well rested after a night’s sleep
- Daytime tiredness or sleepiness
- Irritability, depression or anxiety
- Difficulty paying attention, focusing on tasks or remembering
- Increased errors or accidents
- Tension headaches
- Distress in the stomach and intestines (gastrointestinal tract)
- Ongoing worries about sleep
Someone with insomnia will often take 30 minutes or more to fall asleep and may get only six or fewer hours of sleep for three or more nights a week over a month or more.
When to see a doctor
If insomnia makes it hard for you to function during the day, see your doctor to determine what might be the cause of your sleep problem and how it can be treated. If your doctor thinks you could have a sleep disorder, you might be referred to a sleep center for special testing.
Common causes of insomnia include:
- Stress. Concerns about work, school, health or family can keep your mind active at night, making it difficult to sleep. Stressful life events — such as the death or illness of a loved one, divorce, or a job loss — may lead to insomnia.
- Anxiety. Everyday anxieties as well as more-serious anxiety disorders, such as post-traumatic stress disorder, may disrupt your asleep. Worry about being able to go to sleep can make it harder to fall asleep.
- Depression. You might either sleep too much or have trouble sleeping if you’re depressed. Insomnia often occurs with other mental health disorders as well.
- Medical conditions. If you have chronic pain, breathing difficulties or a need to urinate frequently, you might develop insomnia. Examples of conditions linked with insomnia include arthritis, cancer, heart failure, lung disease, gastroesophageal reflux disease (GERD), overactive thyroid, stroke, Parkinson’s disease and Alzheimer’s disease.
- Change in your environment or work schedule. Travel or working a late or early shift can disrupt your body’s circadian rhythms, making it difficult to sleep. Your circadian rhythms act as an internal clock, guiding such things as your sleep-wake cycle, metabolism and body temperature.
- Poor sleep habits. Poor sleep habits include an irregular sleep schedule, stimulating activities before bed, an uncomfortable sleep environment, and use of your bed for activities other than sleep or sex.
- Medications. Many prescription drugs can interfere with sleep, including some antidepressants, heart and blood pressure medications, allergy medications, stimulants (such as Ritalin), and corticosteroids. Many over-the-counter (OTC) medications — including some pain medication combinations, decongestants and weight-loss products — contain caffeine and other stimulants.
- Caffeine, nicotine and alcohol. Coffee, tea, cola and other caffeine-containing drinks are well-known stimulants. Drinking coffee in the late afternoon and later can keep you from falling asleep at night. Nicotine in tobacco products is another stimulant that can cause insomnia. Alcohol is a sedative that may help you fall asleep, but it prevents deeper stages of sleep and often causes you to awaken in the middle of the night.
- Eating too much late in the evening. Having a light snack before bedtime is OK, but eating too much may cause you to feel physically uncomfortable while lying down, making it difficult to get to sleep. Many people also experience heartburn, a backflow of acid and food from the stomach into the esophagus after eating, which may keep you awake.
Insomnia and aging
Insomnia becomes more common with age. As you get older, you may experience:
- A change in sleep patterns. Sleep often becomes less restful as you age, and you may find that noise or other changes in your environment are more likely to wake you. With age, your internal clock often advances, which means you get tired earlier in the evening and wake up earlier in the morning. But older people generally still need the same amount of sleep as younger people do.
- A change in activity. You may be less physically or socially active. A lack of activity can interfere with a good night’s sleep. Also, the less active you are, the more likely you may be to take a daily nap, which can interfere with sleep at night.
A change in health. The chronic pain of conditions such as arthritis or back problems as well as depression, anxiety and stress can interfere with sleep. Older men often develop noncancerous enlargement of the prostate gland (benign prostatic hyperplasia), which can cause the need to urinate frequently, interrupting sleep. In women, menopausal hot flashes can be equally disruptive.
Other sleep-related disorders, such as sleep apnea and restless legs syndrome, also become more common with age. Sleep apnea causes you to stop breathing periodically throughout the night. Restless legs syndrome causes unpleasant sensations in your legs and an almost irresistible desire to move them, which may prevent you from falling asleep.
- More medications. Older people typically use more prescription drugs than younger people do, which increases the chance of insomnia caused by a medication.
Sleep problems may be a concern for children and teenagers as well. However, some children and teens simply have trouble getting to sleep or resist a regular bedtime because their internal clocks are more delayed. They want to go to bed later and sleep later in the morning.
Nearly everyone has an occasional sleepless night. But your risk of insomnia is greater if:
- You’re a woman. Women are much more likely to experience insomnia. Hormonal shifts during the menstrual cycle and in menopause may play a role. During menopause, night sweats and hot flashes often disturb sleep. Insomnia is also common with pregnancy.
- You’re older than age 60. Because of changes in sleep patterns and health, insomnia increases with age.
- You have a mental health disorder. Many disorders — including depression, anxiety, bipolar disorder and post-traumatic stress disorder — disrupt sleep. Early-morning awakening is a classic symptom of depression.
- You’re under a lot of stress. Stressful events can cause temporary insomnia. And major or long-lasting stress, such as the death of a loved one or a divorce, can lead to chronic insomnia. Being poor or unemployed also increases the risk.
- You work night or changing shifts. Working at night or frequently changing shifts increases your risk of insomnia.
- You travel long distances. Jet lag from traveling across multiple time zones can cause insomnia.
Complications of Insomnia
Sleep is as important to your health as a healthy diet and regular exercise. Whatever your reason for sleep loss, insomnia can affect you both mentally and physically. People with insomnia report a lower quality of life compared with people who are sleeping well.
Complications of insomnia may include:
- Lower performance on the job or at school
- Slowed reaction time while driving and higher risk of accidents
- Psychiatric problems, such as depression or an anxiety disorder
- Overweight or obesity
- Increased risk and severity of long-term diseases or conditions, such as high blood pressure, heart disease and diabetes
- Substance abuse
Preparing for your appointment
If you’re having sleep problems, you’ll likely start by talking to your primary care doctor.
What you can do
To get ready for your appointment:
- Ask if there’s anything you need to do in advance, such as keeping a sleep diary. In a sleep diary, you record your sleep patterns — bedtime, number of hours slept, nighttime awakenings and awake time — as well as your daily routine, naps and how you feel during the day.
- Make a list of any symptoms you’re experiencing, including any that may seem unrelated to the reason for the appointment.
- Take key personal information, including new or ongoing health problems, major stresses or recent life changes.
- Make a list of all medications, vitamins, or herbal or other supplements that you’re taking, including dosages. Let your doctor know about anything you’ve taken to help you sleep.
- Take your bed partner along, if possible. Your doctor may want to talk to your partner to learn more about how much and how well you’re sleeping.
- Make a list of questions to ask your doctor, to make the most of your appointment time.
For insomnia, some basic questions to ask your doctor include:
- What is likely causing my insomnia?
- What’s the best treatment?
- I have these other health conditions. How can I best manage them together?
- Should I go to a sleep clinic? Will my insurance cover it?
- Are there any brochures or other printed material that I can have? What websites do you recommend?
Don’t hesitate to ask questions any time during your appointment.
What to expect from your doctor
A key part of the evaluation of insomnia is a detailed history, so your doctor will ask you many questions.
About your insomnia:
- How often do you have trouble sleeping, and when did the insomnia begin?
- How long does it take you to fall asleep?
- Do you snore or wake up choking for breath?
- How often do you awaken at night, and how long does it take you to fall back to sleep?
About your day:
- Do you feel refreshed when you wake up, or are you tired during the day?
- Do you doze off or have trouble staying awake while sitting quietly or driving?
- Do you nap during the day?
- What type of work do you do?
- What is your exercise routine?
- Do you worry about falling asleep or staying asleep?
About your bedtime routine:
- What is your bedtime routine?
- What do you typically eat and drink in the evening?
- Do you currently take any medications or sleeping pills before bed? Have you ever used sleeping pills in the past?
- What time do you go to bed at night and wake up in the morning? Is this different on weekends?
- Where do you sleep? What’s the noise level, temperature and lighting in this room?
- How many hours a night do you sleep?
About other issues that may affect your sleep:
- Have you experienced stressful events recently, such as divorce, loss of a job or increased demands at work?
- Do you use tobacco or drink alcohol?
- Do you have any family members with sleep problems?
- Have you traveled recently?
- What medications do you take regularly?
Tests and diagnosis
In addition to asking you a number of questions, your doctor may have you complete a questionnaire to determine your sleep-wake pattern and your level of daytime sleepiness. You may also be asked to keep a sleep diary for a couple of weeks if you haven’t already done so.
Your doctor will likely do a physical exam to look for signs of other problems that may be causing insomnia. Occasionally, a blood test may be done to check for thyroid problems or other conditions that can cause insomnia.
If the cause of your insomnia isn’t clear, or you have signs of another sleep disorder, such as sleep apnea or restless legs syndrome, you may need to spend a night at a sleep center. Tests are done to monitor and record a variety of body activities while you sleep, including brain waves, breathing, heartbeat, eye movements and body movements.
Treatments and drugs
Changing your sleep habits and addressing any underlying causes of insomnia, such as medical conditions or medications, can restore restful sleep for many people. If these measures don’t work, your doctor may recommend medications to help with relaxation and sleep.
Behavioral treatments teach you new sleep behaviors and ways to improve your sleeping environment. Good sleep habits promote sound sleep and daytime alertness. Behavior therapies are generally recommended as the first line of treatment for people with insomnia. Typically they’re equally or more effective than sleep medications.
Behavior therapies include:
- Education about good sleeping habits. Good sleep habits include having a regular sleep schedule, avoiding stimulating activities before bed, and having a comfortable sleep environment.
- Cognitive behavioral therapy. This type of therapy helps you control or eliminate negative thoughts and worries that keep you awake. It may also involve eliminating false or worrisome beliefs about sleep, such as the idea that a single restless night will make you sick.
- Relaxation techniques. Progressive muscle relaxation, biofeedback and breathing exercises are ways to reduce anxiety at bedtime. These strategies help you control your breathing, heart rate, muscle tension and mood.
- Stimulus control. This means limiting the time you spend awake in bed and associating your bed and bedroom only with sleep and sex.
- Sleep restriction. This treatment decreases the time you spend in bed, causing partial sleep deprivation, which makes you more tired the next night. Once your sleep has improved, your time in bed is gradually increased.
- Remaining passively awake. Also called paradoxical intention, this treatment for learned insomnia is aimed at reducing the worry and anxiety about being able to get to sleep by getting in bed and trying to stay awake rather than expecting to fall asleep.
- Light therapy. If you fall asleep too early and then awaken too early, you can use light to push back your internal clock. You can go outside during times of the year when it’s light outside in the evenings, or you can get light via a medical-grade light box.
Taking prescription sleeping pills — such as zolpidem (Ambien), eszopiclone (Lunesta), zaleplon (Sonata) or ramelteon (Rozerem) — may help you get to sleep. Doctors generally don’t recommend relying on prescription sleeping pills for more than a few weeks, but several medications are approved for long-term use.
Over-the-counter sleep aids
Nonprescription sleep medications contain antihistamines that can make you drowsy. Antihistamines may initially make you groggy, but they may also reduce the quality of your sleep, and they can cause side effects, such as daytime sleepiness, dizziness, urinary retention, dry mouth and confusion. These effects may be worse in older adults. Antihistamines also can worsen urinary problems, causing you to get up to urinate more during the night.
Lifestyle and home remedies
No matter what your age, insomnia usually is treatable. The key often lies in changes to your routine during the day and when you go to bed. Good sleep habits promote sound sleep and daytime alertness. These tips may help.
- Exercise and stay active. Activity helps promote a good night’s sleep. Get at least 20 to 30 minutes of vigorous exercise daily at least five to six hours before bedtime.
- Check your medications. If you take medications regularly, check with your doctor to see if they may be contributing to your insomnia. Also check the labels of OTC products to see if they contain caffeine or other stimulants, such as pseudoephedrine.
- Avoid or limit naps. Naps can make it harder to fall asleep at night. If you can’t get by without one, try to limit a nap to no more than 30 minutes and don’t nap after 3 p.m.
- Avoid or limit caffeine and alcohol and don’t use nicotine. All of these can make it harder to sleep. Avoid caffeine after lunchtime. Avoiding alcohol can help prevent restless sleep and frequent awakenings.
- Don’t put up with pain. If a painful condition bothers you, make sure the pain reliever you take is effective enough to control pain while you’re sleeping.
- Stick to a sleep schedule. Keep your bedtime and wake time consistent from day to day, including on weekends.
- Avoid large meals and beverages before bed. A light snack is fine. But avoid eating too much late in the evening to reduce the chance of gastroesophageal reflux disease (GERD) and improve sleep. Drink less before bedtime so that you won’t have to urinate as often.
- Use your bed and bedroom only for sleeping or sex. Don’t read, work or eat in bed. Avoid TV, computers, video games, smartphones or other screens just before bed, as the light can interfere with your sleep cycle.
- Make your bedroom comfortable for sleep. Close your bedroom door or create a subtle background noise, such as a running fan, to help drown out other noises. Keep your bedroom temperature comfortable, usually cooler than during the day, and dark. Don’t keep a computer or TV in your bedroom.
- Hide the bedroom clocks. Set your alarm so that you know when to get up, but then hide all clocks in your bedroom, including your wristwatch and cellphone, so you don’t worry about what time it is.
- Find ways to relax. Try to put your worries and planning aside when you get into bed. A warm bath or a massage before bedtime can help prepare you for sleep. Create a relaxing bedtime ritual, such as reading, soft music, breathing exercises, yoga or prayer.
- Avoid trying too hard to sleep. The harder you try, the more awake you’ll become. Read in another room until you become very drowsy, then go to bed to sleep.
- Get out of bed when you’re not sleeping. Sleep as much as you need to feel rested, and then get out of bed. If you can’t sleep, get out of bed after 20 minutes and do something relaxing, such as reading. Then try again to get to sleep.
Many people never visit their doctor for insomnia and try to cope with sleeplessness on their own. Although in many cases, safety and effectiveness have not been proved, some people try therapies such as:
- Melatonin. This over-the-counter (OTC) supplement is marketed as a way to help overcome insomnia. Your body naturally produces melatonin, releasing it into your bloodstream in increasing amounts starting at dusk and tapering off toward the morning. Older people seem to have a greater benefit from melatonin, but no convincing evidence exists to prove that melatonin is an effective treatment for insomnia. It’s generally considered safe to use melatonin for a few weeks, but the long-term safety is unknown.
- Valerian. This dietary supplement is sold as a sleep aid because it has a mildly sedating effect, although it hasn’t been well studied. Discuss valerian with your doctor before trying it. Some people who have used high doses or used it long term may have increased their risk of liver damage, although it’s not clear if valerian caused the damage. When it’s time to stop using valerian, it must be tapered down to prevent withdrawal symptoms.
- Acupuncture. During an acupuncture session, a practitioner places many thin needles in your skin at specific points on your body. There’s some evidence that this practice may be beneficial for people with insomnia, but more research is needed. If you choose to try acupuncture along with your conventional treatment, ask your doctor how to find a qualified practitioner.
- Yoga. Some studies suggest that the regular practice of yoga can help improve sleep quality, and the risks are limited. Be sure to start slow and work with an instructor who listens to you and helps adapt poses to your needs and limitations.
- Meditation. Several small studies suggest that meditation, along with conventional treatment, may help improve sleep. Some research suggests that regularly practicing meditation may have other positive health effects, such as reducing stress and lowering blood pressure.
Because the Food and Drug Administration does not mandate that manufacturers show proof of effectiveness or safety before marketing dietary supplement sleep aids, talk with your doctor before taking any herbal supplements or other OTC products. Some products can interact with medications, and others — such as L-tryptophan, kava or 5-hydroxytryptophan (5-HTP) — can be dangerous on their own.