Insomnia

Insomnia is much more than sleep deprivation or delayed sleep. It’s a sleep disorder that can make it difficult to fall or stay asleep, or both. It can also involve waking up periodically during the night or earlier in the morning than intended or desired.

People with insomnia find it hard to achieve continuous, undisturbed sleep and they often do not feel refreshed and well-rested upon wakening. The result is typically excessive daytime sleepiness (EDS) and impaired thinking and functioning .

Insomnia may occur as a standalone sleep disorder and not a symptom of another health or environmental condition, such as the use of medication or substance abuse. It may also be attributed to another health or environmental condition such as the chronic pain condition fibromyalgia or the mental health condition bipolar disorder.

At times it occurs as a symptom of or alongside another sleep disorder such as obstructive sleep apnea (OSA), the most common form of sleep apnea. OSA occurs when the upper airways get blocked multiple times during sleep, stopping or reducing airflow into the lungs. Around 39 to 55 percent of people with OSA also have insomnia.

How does insomnia differ from occasional sleeplessness?

Bouts of sleeplessness may occur from time to time and come and go without causing serious or lasting problems. They’re often associated with staying up too late, getting up too early, or waking up in the middle of the night. In some cases, these bouts of sleeplessness don’t rise to the level of being classified as a sleep disorder.

In contrast, insomnia can substantially impair physical and mental functioning during waking hours and may lead to serious health complications (see below). Insomnia that persists long-term can also contribute to excess or chronic stress, which can harm your health even further.

How common is insomnia?

Insomnia is the most common sleep disorder in the United States and worldwide. Up to 35 percent of adults in the U.S. report having insomnia, according to the American Academy of Sleep Medicine (AASM). Worldwide, around 1 in 3 adults experiences symptoms of the disorder, with around 10 percent of them meeting the criteria for insomnia disorder.

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Insomnia symptoms involve sleep difficulties and associated issues that occur during waking hours. Signs and symptoms of insomnia include one or more of the following:

• Problems falling asleep
• Trouble staying asleep
• Waking up much earlier than planned or desired

Along with these main symptoms, common associated symptoms or side effects that occur during waking hours include the following:

• Pattern of resisting going to bed at a reasonable hour
• Decreased energy or motivation
• Excessive daytime sleepiness (EDS)
• Fatigue or malaise (feeling unwell in general)
• Making more mistakes and being more prone to injury
• Attention, concentration, or memory impairment
• Behavioral issues such as being more aggressive, hyperactive, or impulsive
• Mood disturbances such as feeling more irritable or agitated
• Negative impact on social and family relationships, as well as work or academic performance

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People can experience different types of insomnia. The main subtypes of the disorder include short-term insomnia (also called adjustment or acute insomnia) and long-term insomnia (also called chronic insomnia).

Short-term (acute) insomnia disorder

Around 30 to 35 of adults in the U.S. experience brief or passing symptoms of insomnia while 15 to 20 percent meet the criteria for short-term insomnia disorder, which lasts less than three months. It’s often brought on by stressful events such as:

• Death of a loved one
• Divorce or a breakup
• Losing a job
• Recent illness, surgery, or onset of pain
• Uncomfortable temperatures, bright lights, noise, and other changes in the environment that make it hard to sleep
• Use of or withdrawal from certain substances such as alcohol, stimulants such as caffeine and nicotine, and illicit drugs such as cocaine and methamphetamine
• Work, school, family, financial, or relationship stress

Acute insomnia episodes may also be due to situations that disrupt the normal sleep-wake cycle, also known as the body’s circadian rhythm. Such is the case for circadian rhythm sleep disorders that cause insomnia, such as jet lag and shift-work sleep disorder.

Short-term insomnia tends to get better once the person addresses or adjusts to the stressor, but symptoms can come and go as different stressors emerge. In some cases, poor sleep may persist even after the original stressor has been resolved.

This is likely the case if you adopt coping behaviors such as drinking alcohol to fall asleep or consuming excessive amounts of caffeine or energy drinks to stay awake, which may seem to help in the short term but can disrupt sleep even more. For some people, acute insomnia symptoms become chronic.

Long-term (chronic) insomnia disorder

Around 10 percent of adults have long-term insomnia disorder, according to the American Academy of Sleep Medicine. In this case, insomnia symptoms occur at least three nights a week for three months or longer and are severe enough to cause disruptions in physical and mental functioning during wakeful hours.

Like short-term insomnia, the chronic type of this sleep disorder can come and go throughout a person’s life and get better or worse over time. But when insomnia symptoms recur, they tend to stick around for months or longer.

Chronic insomnia may be caused or exacerbated by stress, but it may also stem from:

• Certain medications such as some used to treat asthma, colds and allergies, depression, heart arrhythmias, high blood pressure, hypothyroidism (underactive thyroid), seizures, or nicotine addiction
• Irregular sleep schedules or habits, especially those that throw off the body’s circadian rhythm
• Mental health disorders such as anxiety, depression, panic disorder, and post-traumatic stress disorder (PTSD)
• Medical conditions such as asthma, chronic obstructive pulmonary disease (COPD), conditions that cause chronic pain such as cancer and back pain, diabetes, gastroesophageal reflux disease (GERD), heart failure, and high blood pressure
• Neurological disorders that affect the brain, spinal cord, or nerves such as Parkinson’s disease and Alzheimer’s disease—the latter of which can disrupt a person’s circadian rhythm and ability to perceive daily cues that support the sleep-wake cycle
• Other sleep disorders such as sleep apnea, restless legs syndrome (RLS), and circadian rhythm sleep disorders
• Persistent nightmares

Other ways to classify insomnia

Although short- and long-term (or acute and chronic) insomnia are the main ways to classify the condition, other terms may be used by researchers, sleep experts, and healthcare providers (HCPs) as a way to distinguish and assess the various ways the sleep disorder manifests.

These include terms such as:

Sleep-onset insomnia (difficulty falling asleep)

People who experience sleep-onset insomnia may have trouble falling asleep when they attempt to do so. They may toss and turn or simply lie in bed for long durations, often in excess of 30 minutes, but find they still can’t sleep.

Sometimes, people with sleep-onset insomnia have a hard time quieting their minds. They keep thinking about the day’s events or future issues instead of getting their minds to relax and let go of their worries.

Other times, the body’s internal clock, or circadian rhythm, isn’t aligned with the earth’s cycle of daylight and darkness—signals that help control the sleep-wake cycle. As a result, their bodies have a hard time winding down and they can’t fall sleep at bedtimes that are typical for most people. This is often the case for insomnia that occurs due to a circadian rhythm sleep disorder.

Sleep-maintenance insomnia (difficulty staying asleep)

Staying asleep through the night is hard for people with sleep-maintenance insomnia, although they may be able to fall asleep just fine. They wake up one or more times during the night and find themselves struggling to fall back asleep again.

Other times, they find themselves drifting in and out of a restless sleep. This fragmented sleep pattern reduces the amount and quality of sleep, making it more likely that daytime sleepiness and sluggishness will occur.

Early morning awakening insomnia

This term describes waking up well before the desired or planned time. It may go hand-in-hand with sleep-maintenance insomnia, as it might involve not being able to stay asleep long enough for the body and mind to feel fully rested and to function at optimal levels.

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Sleep experts often point to three factors to help explain insomnia causes and risk factors. They are known as predisposition, provocation, and perpetuation. Together, these are referred to as the 3P model of insomnia.

When someone is prone to having a condition or a lower threshold for developing symptoms, this is known as having a predisposition. Provocation involves factors that precipitate or trigger a condition or symptoms. Perpetuating factors may include thoughts, behaviors, or coping mechanisms that cause a condition to persist, even after the trigger that provoked the condition in the first place has been resolved.

Predisposition for insomnia

People with a predisposition for insomnia are prone to the condition or have a lower threshold for developing symptoms. This often involves a combination of biological, psychological, and social factors that increase the likelihood of the disorder occurring.

A prime example of a predisposing factor for insomnia is shift work, although it can also be a provocative (triggering) or perpetuating factor. That’s because working shifts like the night shift can disrupt the body’s natural sleep-wake cycle. This can predispose a person to the sleep disorder, trigger insomnia symptoms, and perpetuate the cycle of troubled or restless sleep.

Other examples of predisposing factors include:

Genetics may increase predisposition toward insomnia

Insomnia tends to run in families. About 30 percent of people with insomnia have a close blood relative (such as a parent or sibling) with the sleep disorder.

People assigned female at birth (AFAB) are more prone to insomnia

Insomnia tends to occur more often in people assigned female at birth (AFAB) compared to people assigned male at birth (AMAB). This may be due to hormone changes that occur in people AFAB at different stages of their lives, such as during pregnancy, perimenopause, and during and after menopause.

For instance, hormone fluctuations that occur during perimenopause and menopause can cause hot flashes and night sweats. They can also increase the frequency and severity of migraines and intensify mental health conditions such as various anxiety disorders, depression, bipolar disorder, and schizophrenia. Alone or together, these factors can make getting a restful night’s sleep more challenging.

Medical and mental health conditions can predispose people to insomnia

These include mental health conditions such as depression and anxiety, medical conditions such as gastroesophageal reflux disease (GERD), and chronic pain disorders such as migraines, rheumatoid arthritis (RA), and psoriatic arthritis (PsA).

Personality traits can increase predisposition toward insomnia

These include people who are easily stressed and worry a lot, including excessively worrying about sleep—sometimes referred to as having insomnia identity. Worrying or being fearful and anxious can lead to hyperarousal, which causes the mind to race and the body’s sympathetic nervous system (SNS) to activate its fight-or-flight response.

The SNS reacts to these thoughts and emotions as though they’re imminent threats that must be addressed. The mind stays hypervigilant while the heart rate, metabolic rate, and levels of the stress hormone cortisol rise, all of which keep your mind and body in a state of high alert. This makes it more likely that you can’t sleep. In essence, you feel “tired but wired.”

Certain personality traits may also play a predisposing or perpetuating role in insomnia, according to a 2023 study published in Frontiers in Psychiatry. People with type D personality (also known as “distressed” personality) tend to experience emotions such as anger, sadness, and worrying more often and are more affected by negative emotions. They also tend to avoid social interactions, fearing they’ll be rejected or disapproved by others.

Type D personality traits can also overlap with other traits such as neuroticism, which is the tendency to experience anger, anxiety, depressed mood, envy, fear, frustration, guilt, jealousy, loneliness, and worry more often than other people. In general, people with insomnia may show signs of high neuroticism.

People with type D personality are more likely to experience more severe insomnia, according to the authors of the Frontiers in Psychiatry study. Highly negative emotions coupled with social inhibition and a lack of social support can make it more likely that they won’t cope well with stress, raising the risk for insomnia.

Provocation of insomnia

Precipitating or provocative factors are required to trigger insomnia, even in people already predisposed to the disorder. These are often associated with events or behaviors that stress the body or mind or keep them in a state of hyperarousal such as:

• Drinking alcohol, smoking tobacco, or consuming caffeine too close to bedtime
• Jet lag due to crossing time zones
• Nighttime tasks, such as needing to get up at night to feed or care for an infant or young child
• Overactive bladder that leads to nocturia (waking up multiple times at night to urinate)
• Stress due to relationship, marital, family, school, work, or financial issues
• Traffic noise
• Uncomfortable temperatures

Perpetuation of insomnia

These are counterproductive thoughts, behaviors, and coping mechanisms that perpetuate insomnia, even after the original trigger has been resolved. In many cases, perpetuating factors can transform short-term insomnia symptoms into chronic ones.

Examples of factors that perpetuate insomnia include:

• Unhealthy beliefs, expectations, or concerns about sleep such as anticipating insomnia symptoms, worrying about how poor sleep will disrupt daytime routines, or feeling anxious about getting in bed for fear of not being able to fall or stay asleep
• Intense focus on solving sleep problems, which is often coupled with unhealthy beliefs about sleep
• Napping, especially for extended periods or too late in the day
• Sleeping in for too long

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Having one or more of these risk factors can raise the risk for insomnia:

High blood pressure raises the risk for insomnia

The link between high blood pressure and insomnia appears to go both ways, as having insomnia may increase the risk of high blood pressure, and vice versa.

How and why this happens isn’t fully understood, but the authors of a 2022 analysis of studies published in the International Journal of Hypertension point to several possible pathways:

Psychological pathway: Insomnia can affect mental well-being, leading to issues such as anxiety and depression. In turn, mental stress increases the activity of the sympathetic nervous system (SNS), a network of nerves that help activate the body’s fight-or-flight response.

The SNS controls automatic body functions such as blood pressure, digestion, heart rate, urination, and sweating. In this case, the overactive SNS triggers vasoconstriction (narrowing of blood vessels), which causes blood pressure to rise.

Nervous system pathway: With or without the psychological component, the increase in SNS activity due to insomnia can raise blood pressure.

Immune system pathway: Insomnia stresses the body, which can trigger the release of the steroid hormone cortisol. Too much cortisol can raise blood pressure, as well as contribute to other health issues that weaken your immune system.

Lifestyle habits can trigger insomnia symptoms

Certain lifestyle habits and routines can raise the risk of insomnia symptoms. In addition to the use of sleep-hampering substances such as alcohol and nicotine, these include:

• Eating spicy foods or heavy meals too close to bedtime
• Engaging in activities that stimulate your brain, such as working late at night, playing video games, and using your smartphone and other light-emitting electronic devices too close to bedtime
• Napping, especially close to bedtime and for long periods
• Sleeping in too long, which can throw off your circadian rhythm and sleep-wake cycle
• Using your bed to perform activities other than sleep and sex, which can lead to your brain associating your bed with wakefulness

Mental health conditions can raise the risk of insomnia

Insomnia commonly occurs in people with certain mental health disorders. For instance, around 40 to 75 percent of people with major depressive disorder (MDD, also called major depression) experience insomnia symptoms that meet the diagnostic criteria for the sleep disorder.

Along with being one of the main symptoms of MDD, insomnia also contributes to the development and progression of the mood disorder. Analyses of studies have shown that people with insomnia are two to three times more likely to develop MDD compared to people who don’t have the sleep disorder. Moreover, insomnia can increase the severity and duration of depression symptoms, as well as raise the risk of relapse after successful depression treatment.

People living with depression and other mental health conditions often find it hard to control their thoughts and emotions. This contributes to staying in a state of hyperarousal, which makes it more difficult to sleep.

Among the symptoms of mood disorders, such as anxiety and major depression, is a tendency to ruminate. Rumination involves repeatedly thinking about or dwelling on negative feelings and stressful situations, as well as their consequences (perceived or real). In short, people who ruminate tend to overthink situations and find it hard to stop doing so, keeping their brains aroused and unable to rest.

Rumination is not confined to mood disorders; anyone can engage in this way of thinking, and when they do, it can contribute to insomnia.

Older adults have an increased risk of insomnia

Although sleep disorders such as insomnia aren’t an inevitable part of the aging process, they tend to occur more often as people age. Roughly 30 to 50 percent of older adults report symptoms such as difficulty falling or staying asleep, with sleep-onset insomnia occurring 35 to 60 percent of the time and sleep-maintenance insomnia occurring 50 to 70 percent of the time.

Around 25 percent of older adults also experience nonrestorative sleep, or sleep that leaves them feeling unrefreshed in the morning. This may be because sleep efficiency tends to decrease after age 60, with adults in this age group spending less time in the last and deepest stages of the sleep cycle.

Sleep generally consists of five progressive stages:

• Stage W: wakefulness
• Stage N1: non-rapid eye movement (non-REM) stage 1 or relaxed wakefulness
• Stage N2: light sleep
• Stage N3: deep or slow-wave sleep
• Stage R: rapid eye movement (REM) sleep (also known as the dreaming stage)

Because older adults spend less time in stages N3 and R, their sleep is more easily disturbed or disrupted. Moreover, biological factors such as circadian rhythm changes can lead to less deep sleep and more fragmented sleep, as well as early morning awakenings.

Like younger people, provocation factors in older adults may include medical and mental health problems, stress, and poor sleep habits or coping behaviors. But older adults may be more sensitive to these triggers as they may be more likely to have multiple chronic health conditions and use numerous medicines, many of which can affect sleep.

Social isolation, caregiving, and bereavement raises the risk of insomnia

Many older adults experience social isolation. Being socially isolated contributes to loneliness, higher levels of stress, and greater risk of heart attack and stroke, along with higher rates of depression, anxiety, and suicide.

Some older adults may also serve as round-the-clock caregivers for spouses, partners, or parents. Others may be grieving the loss of a spouse or partner. All of these factors can precipitate and perpetuate insomnia in older adults.

Substance use can amplify the risk of insomnia

Certain substances can impair sleep and cause insomnia. In addition to medicines used to treat certain health conditions, other substances that impact sleep include the following:

Alcohol impairs sleep

Alcohol can disrupt the sleep-wake cycle and cause fragmented, poor quality sleep. But the negative effects of this relationship go both ways. Around 36 to 91 percent of people with alcoholism (alcohol dependence) have insomnia. Meanwhile, roughly 15 to 30 percent of people report drinking to manage insomnia symptoms.

People can quickly build a tolerance to the sedative (sleep-inducing) effects of alcohol, further affecting sleep and the risk of drinking problems. Chronic insomnia also raises the risk of alcohol addiction relapse.

Cannabis can make it harder to sleep

People may also use cannabis (marijuana) to help them relax and fall asleep. But like alcohol, people can also develop a tolerance to marijuana’s sedative effects.

According to a 2022 review published in Nature and Science of Sleep, no sufficient evidence was found that cannabinoids are a safe and effective treatment for sleep disorders. The researchers pointed out, however, that more investigation should be done, as current research is limited.

Caffeine can lead to insomnia

Having too much caffeine can contribute to insomnia. That’s because it’s a stimulant that can stay in your system for hours after you consume it. This can make it harder to fall asleep, especially if consumed too close to bedtime.

Nicotine can disrupt sleep

Although some people turn to nicotine to help them relax, nicotine is actually a stimulant that can lead to sleep disturbances. A 2019 review of studies published in Nicotine & Tobacco Research found that people who smoke are more likely to go to bed later, report more sleep issues such as difficulty falling and staying asleep, and sleep less overall. They spend less time in deep sleep and experience more restless sleep, as well as greater daytime sleepiness.

Traumatic brain injury (TBI) heightens the risk of insomnia

Sleep disruptions occur in roughly 27 to 72 percent of people with traumatic brain injuries (TBIs). These are caused by significant head trauma such as blows, bumps, or jolts to the head or hits to the body that cause the brain to move quickly and violently back and forth against the skull.

Sleep disturbances that may result include insomnia, daytime sleepiness, and hypersomnia—a condition that causes excessive daytime sleepiness despite sleeping for extended periods. The risk of sleep issues such as these are higher in people with TBIs, regardless of whether they’ve had problems sleeping in the past.

Along with raising the risk of accidents and further injury and making depression, stress, and pain feel worse, these sleep disruptions increase lethargy and attention deficits. They also decrease brain functions such as thinking, reasoning, learning, and remembering—all of which are already impacted by TBI.

Sleep deficits also impede the natural process of brain recovery that takes place during healthy sleep.

Children and adolescents get insomnia

Insomnia is common among children and adolescents. In some cases, the sleep disorder becomes chronic. Common insomnia symptoms experienced by infants and toddlers include:

• Difficulty falling sleeping without help from a caregiver
• Frequent or prolonged nighttime waking with problems returning to sleep without help
• Resisting going to bed
• Sleep-onset insomnia

Other insomnia symptoms include:

• Frequent "curtain calls" after getting in bed (such as asking for water, hugs, or more bedtime activities, such as reading)
• Resistance to an appropriate sleep schedule
• Trouble waking in the morning or getting up for school
• Waking up too early

Insomnia in children can contribute to issues during waking hours such as:

• Attention, concentration, or memory impairment
• Behavioral issues such as hyperactivity coupled with aggressive or oppositional behavior
• Decline in academic performance
• Fatigue, tiredness, or daytime sleepiness
• Irritability and other mood changes
• Less motivation
• Low frustration tolerance
• Poor decision-making and impulse control
• Social or family problems

Attention-deficit/hyperactivity disorder (ADHD), which occurs in children and adults, can trigger and promote hyperarousal, making it more difficult for people with the condition to sleep. Stimulants used to treat ADHD can also worsen insomnia symptoms. Sleep issues are also common in people with autism spectrum disorder (ASD), starting during childhood and persisting into adulthood.

Military staff and veterans are at increased risk for insomnia

Active duty military staff are at high risk for insomnia. Many veterans also report sleep issues, with around 50 percent experiencing insomnia symptoms.

Rates of insomnia among military service members have risen since 2001, the year thousands of U.S. troops were first deployed overseas as part of Operating Enduring Freedom (OEF) and in response to the 9/11 terrorist attacks. Since OEF began, the rates of insomnia associated with deployment and combat exposure have climbed dramatically.

Service members who have been deployed may experience insomnia due to:

• Changes in their sleeping environment
• Higher noise levels
• Jet lag
• Shift work, with those who work night shifts reporting more difficulties falling asleep and disturbed sleep during daylight hours due to loud noises surrounding them
• Stress and anxiety associated with prolonged separation from family members, or associated with fear of injury or death during deployment
• Uncomfortable temperatures

Furthermore, insomnia symptoms often persist after service members finish deployment. Sleep-onset and sleep-maintenance insomnia often continue for months after returning home.

Moreover, the risk of related conditions doubles and sometimes triples among military staff. These include higher rates of conditions such as:

• Anxiety
• Diabetes
• GERD
• Obstructive sleep apnea
• Overweight and obesity
• PTSD

More than 90 percent of veterans with PTSD also report sleep disturbances, most of which involve insomnia and nightmares. In particular, trauma-related nightmares associated with events that occurred during deployment or combat can cause veterans with PTSD to suddenly wake up with intense anxiety. It’s been suggested that insomnia has contributed to an elevated suicide risk among veterans, as it worsens symptoms of mental health conditions such as depression and PTSD.

Pregnancy affects insomnia risk

Close to 40 percent of all pregnant people experience sleep difficulties, such as sleep-onset and sleep-maintenance insomnia, according to a 2021 analysis of studies published in the Journal of Sleep Research.

In addition to hormone changes, other factors that contribute to insomnia during pregnancy include issues with:

Breathing: Shortness of breath may occur during pregnancy due to the pressure placed on the lungs by the growing uterus, especially while lying down. Hormone changes may also increase the risk of sleep apnea.

Comfort: Body composition and weight changes can cause discomfort during pregnancy, including making it harder to find a comfortable sleeping position.

Heartburn: Around 30 to 50 percent of pregnant people experience GERD symptoms during pregnancy, such as heartburn and reflux, which can feel worse when lying down. The burning sensation felt in the upper abdomen or chest area and reflux (regurgitation) of foods and acidic liquids can feel painful and make it hard to sleep.

Leg sensations: The risk of restless legs syndrome goes up during pregnancy, especially during the third trimester. The syndrome causes uncomfortable, painful leg sensations to occur mainly when resting, triggering an urgent need to move them.

Urinary frequency: Nocturia is common during pregnancy.

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To help diagnose insomnia, an HCP will talk with you about current symptoms, medical history, and sleep habits. For instance, they might ask:

• How often you can’t sleep or sleep well, as well as how long you’ve had this issue
• How long it usually takes you to fall asleep at bedtime
• How often you wake up at night and how long it takes you to fall back asleep
• How refreshed you feel upon waking and how tired you feel during waking hours
• What your usual bedtime and wake times are, including on your days off from work or school
• How frequently and loudly you snore or wake up feeling short of breath or gasping for air
• Whether you have any new or chronic health conditions
• Whether you take any medicines, including those prescribed and taken over the counter (OTC) along with dietary and herbal supplements and essential oils
• If you’re pregnant or going through perimenopause or menopause
• Whether you consume alcohol or caffeine products or use cannabis, nicotine, or illegal drugs such as cocaine or methamphetamines

A physical exam will then be conducted to rule out any physical issues that might disturb your sleep. This includes listening to your heart and lungs, as well as looking for signs that point to sleep apnea as a contributing factor for insomnia, such as high blood pressure, an irregular heartbeat, and enlarged tonsils or neck circumference.

And although there’s no specific blood test to diagnose insomnia, your HCP may recommend certain blood tests to confirm or rule out suspected medical conditions contributing to your insomnia symptoms, such as thyroid tests to rule out a type of thyroid disease called hyperthyroidism (overactive thyroid).

Your responses to these questions and the results of your physical exam and lab tests will help your HCP determine whether your insomnia symptoms are an isolated or passing event, or if you have short- or long-term insomnia disorder. It also helps them pinpoint whether your sleep troubles may be the result of another health condition, medicines you take, or other causes.

What to include in a sleep diary

Your HCP may ask you to keep a sleep diary or journal for one to two weeks prior to your appointment to help with the diagnosis. This involves completing a daily log with information and behaviors that are related to sleep, including:

• What time you got into bed
• What time you tried to fall asleep
• How long it took you to fall asleep
• How many times you woke up and for how long
• What time you woke up in the morning (or the time of day or night you first got up to start your day)
• Total hours of sleep
• Sleep quality
• Factors that disturbed your sleep (such as loud noises, uncomfortable bed or temperatures, pain, or getting up to care for your child, pet, or loved one)
• When and how much caffeine you had in the morning, afternoon, and evening
• Whether you had a heavy meal, alcohol, caffeine, or nicotine two to three hours before bedtime
• When and how much exercise you got
• Whether and how long you napped
• Medicines you took, including prescription and OTC medicines along with dietary and herbal supplements and essential oils
• Bedtime routine in the hour leading up to getting into bed

Organizations such as the National Sleep Foundation provide sleep diary templates you can use to document this information or your HCP may provide you with one. Along with a written diary, you can also use a wearable device or smartphone app to track your sleep. The Sharecare app, available for iOS and Android devices, offers a sleep-tracking feature.

What does a sleep study involve?

Once these initial steps have been completed, your HCP might also recommend a noninvasive sleep study conducted at home or a sleep lab to check for insomnia and other sleep disorders. Sleep test options your HCP might prescribe include:

Actigraphy

This involves wearing a watch-like device on your wrist called an actigraph for anywhere from 3 to 14 days. The device senses and records activity, motion, and sleep-wake patterns throughout the day and night. This helps your HCP assess how much and how well you’re sleeping, as well as what times you fall asleep and wake up.

Home sleep apnea test

This test is conducted at home using a portable recording device. It requires you to attach device sensors to your face and finger and wear a respiratory inductive plethysmography (RIP) belt around your chest. The RIP belt detects when your torso expands, especially your chest and abdomen, as you breathe while the sensors measure changes in your breathing and oxygen levels while sleeping that might point to sleep apnea as a contributor to your insomnia symptoms and poor sleep quality overall.

Polysomnography

If your HCP suspects an underlying sleep disorder or your insomnia symptoms haven’t been sufficiently relieved with treatment, they may recommend polysomnography (also called a polysomnogram). This an overnight sleep study conducted at a sleep lab. It can also be scheduled during the day, if your work or other obligations don’t allow for an overnight stay.

The painless test involves attaching sensors in strategic areas of your scalp and body such as your chest, arms, or fingers. While you sleep, these sensors record brain waves, breathing, heart rate, movement, oxygen levels, and other bodily functions.

A medical technician, technologist, or nurse will place these sensors on you and monitor you via video and audio monitors. The polysomnogram sensors alert them to unusual or concerning readings, and they can see, hear, and record what’s happening while these occur. It also allows them to promptly intervene, if needed, such as if you’re having a seizure or your oxygen levels dip too low.

Along with helping to diagnose insomnia, sleep apnea, and seizures, polysomnography can help your HCP diagnose other sleep disorders that contribute to or are associated with insomnia such as:

• Hypersomnia
• Periodic limb movement disorder (PLMD): PLMD causes repetitive limb movements that cause the arms, legs, or both to jerk or twitch, disrupting sleep and causing daytime sleepiness.
• Night (or sleep) terrors: These are episodes of screaming, intense fear, and flailing during the first three to four hours of sleep or non-REM sleep (unlike nightmares which occur during REM sleep), causing a person to quickly awaken in a terrified state.
• Nocturnal panic attacks: This is a sudden and intense feeling of fear that causes you to wake up in a state of panic, gasping for air, with your heart pounding.
• Sleep paralysis: This is a brief loss of muscle control (called atonia), which makes you temporarily unable to move just after falling asleep or just as you’re waking up. It’s described as a mixed state of consciousness, somewhere between REM sleep and wakefulness, often causing you to hallucinate or continue with the dreamlike state of REM though you’re somewhat awake and aware of what’s going on.
• Sleepwalking (formerly called somnambulism): This sleep disorder causes you to walk or perform other complex behaviors while still asleep or mostly so.

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Insomnia, especially long-term insomnia, can have a profound impact on your health and well-being. Trying to perform complex tasks that require you to be fully awake, alert, and focused can be difficult and even dangerous. People who are sleep-deprived are at much greater risk for injuries and accidents, including motor vehicle accidents.

The sleep disorder can raise the risk for several conditions and can exacerbate certain health conditions you may already have.

For example, insomnia can raise the risk for heart attack and stroke.

Insomnia may also exacerbate existing cases of asthma, chronic obstructive pulmonary disorder (COPD), and chronic pain. And it may also have the effect of raising the risk of or exacerbating cases of the following conditions:

• Anxiety and depression
• Conditions that can cause psychosis, such as bipolar disorder, schizophrenia, and postpartum psychosis (a severe mental health emergency related to postpartum depression)
• Heart disease
• Heart failure
• High blood pressure
• Obesity
• Pregnancy complications such as more pain during labor, premature birth, and low birth weight for the baby
• Substance abuse
• Suicide
• Type 2 diabetes

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Your HCP can work with you to create an effective insomnia treatment plan. They’ll consider:

• What symptoms you’re experiencing
• How long you’ve had them
• How they’re affecting your daily life
• Which factors might be contributing to them
• Which treatments you prefer

Short-term (acute) insomnia treatment

Acute insomnia symptoms may not require a specific treatment plan. Instead, effective management usually comes down to practicing good sleep hygiene practices. If these techniques don’t relieve your symptoms sufficiently, be sure to talk with your HCP to determine next steps.

What is sleep hygiene?

Sleep hygiene involves lifestyle strategies that support sound and restful sleep. These healthy sleep habits include:

Sleep-wake schedule and bedtime routine

To help prepare your body and mind for sleeping, try to:

Stick with a stable sleep schedule. Aim to go to bed and wake up around the same time each day, including when you’re off from work or school. Determine your target bedtime based on your target wake-up time and try to stay true to these set times. This helps solidify your body’s sleep-wake cycle and gets your mind and body into the routine of sleeping and waking at usual times.

Set up a sleep sanctuary that invites and supports sleep. Steps might include the following:

• Choose a mattress and pillow that are comfortable and don’t cause or aggravate pain.
• Turn off or dim lights to help stimulate the production of melatonin, a hormone naturally produced by the brain’s pineal gland to promote sleepiness.
• Avoid noise by turning off or tuning out irritating or stimulating sounds (using a sound machine, fan, or ear plugs, if desired).
• Set your bedroom temperature to your sleep preferences (leaning toward the cooler side). Around 65-degrees Fahrenheit is a good rule of thumb.
• Try using soothing scents to relax your mind and quiet your thoughts.

Set aside at least 30 minutes for winding down and letting go of stressors. Whether it’s listening to soothing music, doing gentle yoga, reading, or soaking in a warm bath, build relaxation into your routine to help you reach a state of calmness before bedtime.

Turn off the electronics. Devices that emit blue light such as smartphones, tablets, and laptops can decrease melatonin production and keep your mind stimulated. Shut off these devices around 30 to 60 minutes before your target bedtime to help your brain prepare for sleep.

Limit what you do in bed. Reserve your bed for sleep and sex only. This helps your brain link your bed mainly with sleep instead of other sleep-disruptive activities.

Get out of bed if you can’t sleep. Staying in bed and tossing and turning for hours conflicts with the good sleep habits you’re trying to establish—that your bed is meant for sleep. If you haven’t fallen asleep after about 20 minutes of trying, get up and go into another room, read, or do another calming activity in low light before you give sleeping another try. Avoid turning on your light-emitting electronic devices during this time.

Daytime sleep habits that cultivate quality sleep

During daytime or waking hours, aim to support your body’s circadian rhythms with these healthy habits:

Avoid naps. Try not to nap unless your safety is at risk. If you find yourself nodding off while driving, for example, pull over somewhere safe and take a short power nap for your sake and that of others. Better yet, don’t drive if you’re sleepy. If that afternoon slump makes it too hard to resist taking a midday nap, limit it to around 20 minutes and try to take it by early afternoon at the latest.

Reduce caffeine consumption. Try not to consume caffeine in the late afternoon or evening. Doing so can keep your mind roused instead of relaxed and ready to sleep.

Eat earlier and lighter. Eating heavy or spicy meals or snacks late in the evening may not give your body enough time to digest before you lie down. This makes it more likely that you’ll experience heartburn, indigestion, and other digestive issues that disrupt sleep.

Let sunlight shine through. Getting exposure to light in the morning, especially natural sunlight, helps keep your circadian rhythm and sleep-wake cycle in harmony.

Limit or avoid alcohol. Alcohol’s sedative effects don’t last. While drinking may initially make you feel sleepy, consuming alcohol in the evening or too close to bedtime can disrupt your sleep, as your body breaks down and metabolizes the substance.

Stay away from nicotine. Using nicotine products too close to bedtime can keep your mind and body stimulated, disrupting sleep and making insomnia more likely. If possible, try to quit nicotine altogether to help support restorative sleep and your overall health.

Exercise routinely. Engaging in moderate-to-vigorous physical activity on a regular basis can help you sleep better at night. Try to work out by early afternoon instead of too close to bedtime, though, to help ensure your body and mind aren’t revved up when you turn in for the night.

Long-term (chronic) insomnia treatment

Improving the quality and duration of sleep and minimizing issues during waking hours are the two main goals of chronic insomnia treatment. Your HCP will likely recommend starting with cognitive behavioral therapy for insomnia (CBT-I) and other lifestyle interventions. If these don’t help you manage your insomnia symptoms, an OTC or prescription sleep aid may be added to your care plan for a limited duration.

Cognitive behavioral therapy for insomnia

CBT-I is often the first chronic insomnia treatment recommended by HCPs and sleep experts. Scientific evidence has shown that this form of talk therapy has lasting benefits and fewer health risks and side effects compared to some medicines with sedative properties such as benzodiazepines (also called benzos or BZDs). These benefits often last even after therapy sessions have been completed, unlike sedatives.

Moreover, CBT-I can benefit people with insomnia and co-existing physical and mental health conditions such as alcohol dependence and chronic pain conditions such as fibromyalgia, major depression, and PTSD.

CBT-I is often provided by a licensed mental health provider, such as a psychologist, who’s been trained in this form of CBT for sleep disorders. The treatment helps pinpoint the stressors, anxieties, and negative beliefs and behaviors contributing to sleep loss, and then helps replace these with more helpful, practical, and realistic behaviors, beliefs, and perceptions.

Along with sleep hygiene techniques, CBT-I may also incorporate:

Relaxation training: A CBT-I practitioner can teach people with insomnia various relaxation methods recommended for the sleep disorder such as progressive muscle relaxation. This relaxation method involves tightening and relaxing your muscles, starting with your face and working downward toward your feet. A therapist may also prescribe biofeedback, which helps people gain better control of body functions affected by stress and anxiety such as blood pressure, breathing rate, and heart rate. Practicing these can help relieve insomnia symptoms and bolster sleep.

Sleep restriction and compression: This involves reducing sleep time to help improve sleep quantity and quality. The CBT-I practitioner uses information logged in the patient’s sleep diary to calculate the amount of time spent lying in bed awake versus the amount of time actually sleeping. Sleep restriction involves substantially cutting down the amount of time spent in bed while sleep compression gradually pares down the time spent in bed. Both are a means to the same end: to spend less time in bed awake and more time sleeping.

Stimulus control: These are a series of steps people can take to alleviate anxiety about sleep and cultivate a positive relationship with their sleep environment. This might entail removing certain elements from the bedroom that keep the mind alert and aroused, such as the TV, laptop, and other light-emitting electronic devices. It might also employ tactics such as only lying down when you feel tired, setting the alarm for the same wake time each day, and limiting or avoiding napping, especially for prolonged periods.

Despite recommendations and strong scientific support for CBT-I, few people receive this insomnia treatment because of the lack of clinicians trained in it. You can ask your primary HCP for a referral to a licensed CBT-I provider or find and verify practitioner credentials through professional healthcare organizations such as the:

• American Board of Sleep Medicine
• American Psychological Association
• Association of Behavioral and Cognitive Therapies
• Society of Behavioral Sleep Medicine

In some cases, virtual (telehealth) therapy sessions with a licensed CBT-I practitioner may be an option if a qualified practitioner isn’t available in your area or if it’s hard for you to make it to sessions in person. Ask your HCP or health insurance agent for a telehealth referral if you’re interested in this option.

Sleep aids for insomnia

Although sleep aids—such as OTC and prescription medicines and dietary and herbal supplements—aren’t generally recommended as the first line of treatment for insomnia, your HCP may recommend a short or intermittent course. Sleep aids are recommended for use in conjunction with (instead of as a replacement for) sleep hygiene and CBT-I.

Your HCP may prescribe or recommend a specific sleep aid based on your:

• Age
• Health conditions
• Insomnia type, duration, and symptoms
• Other medicines
• Preferences

Prescription medicines used to treat insomnia

These include:

Antidepressants: Some medicines used to treat depression can help alleviate insomnia symptoms, including preventing early morning awakenings. These include lower doses of the tricyclic antidepressants (TCA) paroxetine, trazadone, and trimipramine, as well as very low doses of the TCA doxepin.

Benzodiazepines: These are an older class of sedative-hypnotic drugs used to treat insomnia by relaxing the muscles, causing sleepiness, and lessening anxiety. In the U.S., benzos prescribed to treat insomnia include flurazepam, quazepam, temazepam, and triazolam.

Dual orexin receptor antagonists (DORAs): Also called orexin receptor antagonists, DORAs block a chemical in the brain called orexin that helps keep you awake and alert. Examples include daridorexant, lemborexant, and suvorexant.

Melatonin receptor agonists: These prescription medicines, including ramelteon, increase production of melatonin in the body.

Nonbenzodiazepines (Z drugs): These sedative-hypnotics are relatively similar to benzos, but have fewer side effects since they tend to slow down activity in parts of the brain that regulate sleep and have less of an effect in other areas of the brain.

Z drugs are usually short-acting sleep aids. Therefore, they’re less likely to cause daytime grogginess and sleepiness. Some may be prescribed for longer periods. These include eszopiclone, zaleplon, and zolpidem.

Seizure medicines (anticonvulsants): Some anticonvulsants can help with insomnia by treating conditions that keep you from falling or staying asleep such as restless legs syndrome. These include off-label prescriptions for gabapentin and pregabalin.

“Off-label” means the treatment is being prescribed or used for purposes or conditions other than what’s been approved by the U.S Food and Drug Administration (FDA) and printed on the medication label. Although off-label use is a common and often effective practice, there is less scientific data about the safety and effectiveness of drugs used for off-label purposes.

OTC sleep aids used to manage insomnia

Although OTC medicines and supplements may be used for short or occasional bouts of insomnia, they’re usually not recommended for chronic insomnia treatment due to the risk of side effects associated with their long-term use.

Dietary and herbal supplements and essential oils aren’t classified by the FDA as drugs used to treat or prevent disease. As a result, the agency doesn’t regulate these products and the claims made on their labels. Information about a supplement’s safety, effectiveness, side effects, purity, ingredient accuracy, and dosing may be lacking.

It’s therefore best to discuss OTC options with your HCP and conduct your own thorough research before trying any of these sleep aids.

Examples of OTC sleep aids used to ease insomnia symptoms include:

Antihistamines: These medicines block histamines, a substance released by the immune system that causes allergies. Antihistamines, such as diphenhydramine and doxylamine, can also make you sleepy. Note that tolerance to these drugs can quickly develop after taking them for only a short duration, so they tend to become less effective as you use them over time.

Dietary and herbal supplements: Some OTC supplements have been used as natural remedies for insomnia. These include chamomile, kava kava, and valerian. Some of these products combine various ingredients and dosages into chewable, liquid, pill, powder, or tea forms.

Melatonin: Like its prescription counterpart, short-term use of OTC melatonin may help promote sleep. Since it helps regulate the sleep-wake cycle, melatonin may be better at treating circadian rhythm disorders such as jet lag and delayed sleep phase disorder (sleep issues caused by repeatedly going to sleep and waking up late) and less effective as an insomnia treatment.

Aromatherapy (essential oils) for insomnia

Aromatherapy is an ancient mind-body therapy that uses essential oils derived from plants to support health. It’s been practiced for thousands of years as an approach for managing a variety of ailments. In more recent years, aromatherapy has gained traction among the public and Eastern and Western HCPs as a complementary treatment for conditions such as anxiety, depression, stress, pain, and insomnia.

Aromatherapy involves inhaling the scents or vapors of substances derived from plants. Examples of essential oils used to ease insomnia symptoms include those made with:

• Galphimia glauca (goldshower or “calderona amarilla”)
• Humulus lupulus (hops)
• Matricaria chamomilla (chamomile)
• Melissa officinalis (lemon balm)
• Passiflora edulis (passionflower)
• Piper methysticum (kava)
• Valeriana officinalis (valerian)
• Withania somnifera (ashwaganda)

What are the risks and side effects of sleep aids?

Many effective sleep aids require a prescription because of their risks and potential for side effects. In any case, it’s best to limit the use of sleep aids for insomnia and only use them as instructed by your HCP.

It’s also important to discuss the benefits, risks, and side effects of any sleep aid before taking it. These risks and side effects may include:

Complex and sometimes risky sleep behaviors

Certain sleep aids, such as zolpidem, have been known to cause complex behaviors that can raise the risk of injury while the person taking them isn’t fully awake and aware of what they’re doing. In addition to getting out of bed and potentially falling, these include behaviors and activities such as driving and eating while in a trance-like state.

Sleep medicine drug interactions

There is a high potential for drug interactions between sleep medicines, including natural sleep aids, and other prescription and OTC medicines and supplements you may be taking. These interactions can reduce or intensify the potency of various medicines and supplements.

Inaccurate sleep supplement ingredient lists

Because they’re not classified as medicines, the FDA doesn’t regulate products such as dietary and herbal supplements, including those used for sleep disturbances such as insomnia. As such, product labels may not accurately reflect the dose, ingredients, or substances consumed.

Increased risk of motor-vehicle accidents tied to sleep aids

Sleep aids have been tied to a higher risk of motor-vehicle accidents. That’s because many sleep aids can reduce alertness, impair judgment, and slow down reaction time when driving, with an overall effect comparable to driving under the influence of alcohol or other mind-altering substances.

Lingering grogginess and drowsiness

Sleep aids can cause residual effects such as trouble thinking clearly and concentrating and feeling groggy or drowsy for much of the day after. Balance can also be affected by these symptoms, placing people at greater risk of falling, especially older adults and people with conditions that affect thinking or balance such as dementia or multiple sclerosis.

More sleep disturbances due to sleep aids

Sleep aids can alter the balance of natural substances and functions in your body involved in sleep, influencing the way you sleep. They can negatively impact sleep quality and the body’s progression through the stages of sleep. Some can also affect breathing by suppressing the areas of the brain that control this function, raising the risk of fragmented sleep and sleep apnea.

Risk of addiction (habit formation) using sleep aids for too long

Some people become dependent on sleep aids, meaning they feel they can’t sleep without taking them. They may become anxious, irritable, nervous, or experience disturbing dreams if they stop taking the sleep aid.

Risk of overdose from sleep medicines

In addition to causing symptoms such as confusion and delirium, some of the older sleep aids such as benzos can suppress or substantially slow down breathing, weaken the pulse, cause cyanosis (bluish to purplish tint to the lips, fingernails, and skin due to low oxygen levels in the blood), and raise the risk of death. This is especially true if the dose taken exceeds the amount prescribed or recommended on the drug label.

Tolerance to sleep aids

This is when a drug or substance has a diminished effect because the body adapts to its continued presence with repeated use. Increasingly higher doses are often needed to have the same effect, or a new sleep aid must be started.

Withdrawal symptoms caused by suddenly stopping sleep medicines

Rebound insomnia (return and worsening of insomnia symptoms), increased anxiety, and other withdrawal symptoms can occur if you take certain sleep aids for more than a few days and abruptly stop taking them. An HCP can help you create a plan to slowly reduce the dose of the sleep aid over the course of several weeks before you stop taking it altogether.

Other ways to manage insomnia

Other strategies you may want to explore to help you sleep include:

Deep breathing: Also called pranayamic or 4-7-8 breathing, you inhale through your nose for four counts, hold your breath for seven counts, and exhale through your mouth for eight counts. These slow, deep breaths help ease tension in your body and quiet your mind. Doing so may help calm your nervous system and ready your brain for sleep by reducing stimuli that keep it aroused.

Imagery: Get into a comfortable position, close your eyes, and imagine a peaceful scene that feels relaxing, such as a natural, serene setting. Add details as you visualize this image such as the scents and sounds of ocean waves lapping the shore. Practicing this technique shortly before bedtime can relax your mind and body as you prepare to sleep.

Mindfulness meditation: This practice directs your attention to the pace of your breaths and the present moment, without judgment or fear. It may help reduce anxiety and rumination, which in turn may help prevent and ease insomnia symptoms.

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While some causes and risk factors for insomnia (such as smoking, drinking alcohol, or having caffeine too late in the day) can be prevented or changed, others aren’t fully understood. Although insomnia can’t always be prevented, there are many insomnia treatment strategies and lifestyle approaches you can try to help you sleep better.

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Talk with an HCP if you’re having insomnia symptoms that persist or recur often, especially if they have a negative impact on your mood, cognitive and physical functions, performance at work or school, and other facets of your daily life.

Even if you’re not experiencing long-term symptoms, it’s worth talking with an HCP about your insomnia symptoms, what could be causing them, and options for managing them. Also be sure to talk with an HCP if your current insomnia treatment plan is no longer keeping your symptoms in check, you’re having new or worsening insomnia symptoms, or have a physical or mental health condition that affects when, how much, and how well you sleep.

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Living with insomnia can feel frustrating and sometimes overwhelming, especially if symptoms persist for long periods of time. Insomnia can disrupt your life, lower your mood, and turn sleep into a chore you dread instead of a welcome relief at the end of your day.

On the bright side, there are many tried-and-true options for preventing, treating, and sometimes curing insomnia. The first step is to reach out to your HCP for help with developing the optimal plan for you.

And if this plan isn’t working well, reach out to your HCP again and shift your strategy. Not all insomnia treatments, sleep-hygiene techniques, and lifestyle strategies work in the same way for everyone. A bit of persistence and trial and error may be needed to find the best approach for you.

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• Defining the Different Types of Insomnia
• 5 Surprising Triggers of Insomnia
• Signs You Should Talk to a Doctor About Insomnia