What is insomnia and what causes it?
Insomnia is difficulty falling or staying asleep,
the absence of restful sleep, or poor quality of sleep.
Insomnia is a symptom and not a disease. The most common
causes of insomnia are:
- medications,
- psychological
conditions (for example, depression,
anxiety), - environmental
changes (travel, jet lag, or altitude changes), and - stressful events
or a stressful lifestyle.
Insomnia can also be caused by poor
sleeping habits such as excessive daytime naps or
caffeine
consumption and poor sleep hygiene.
The American Academy of Sleep Medicine estimates 30% of adults have some symptoms of insomnia, 10% have insomnia symptoms so severe they cause consequences such as daytime sleepiness, and less than 10% have chronic insomnia.
Insomnia may be classified by how long the symptoms are
present.
- Transient insomnia usually is due to situational
changes such as travel, extreme climate changes, and stressful events. It lasts for
less than a week or until the stressful event is resolved. - Short-term insomnia usually is due to ongoing stressful lifestyle
or events,
medication side effects or medical conditions and lasts for one to three weeks. - Chronic insomnia (long-term insomnia) often results from
depression, digestive problems, sleep disorders, or substance abuse and continues for more than three weeks.
Transient insomnia may progress to short-term insomnia and without adequate treatment short-term
insomnia may become chronic insomnia.
Some of the medications and substances that can contribute
to insomnia are:
- caffeine and coffee,
- tobacco,
- alcohol,
- decongestants (for example, pseudoephedrine),
- diuretics (for example, furosemide
[Lasix],
hydrochlorothiazide
[Dyazide]) especially if taken in the evening or at
bedtime, - antidepressants (for example,
bupropion
[Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban],
fluoxetine [Prozac]), - appetite suppressants (for example,
sibutramine [Meridia],
phentermine [Fastin]), and - amphetamines.
Insomnia also may be the result of withdrawal from:
- benzodiazepines
(for example,
diazepam [Valium],
chlordiazepoxide
[Librium],
lorazepam [Ativan]), - alcohol,
- antihistamines,
- amphetamines,
- cocaine,
- marijuana, and
- other addicting drugs.
Insomnia can also result from poor sleep-related habits (poor sleep hygiene).
What are natural treatments for insomnia?
There are several ways insomnia may be treated without use of
medication. These include behavioral modification and use of natural herbal
remedies.
When a person consults a doctor about insomnia, they may be asked to keep a sleep log for several weeks to monitor sleep habits. The treatment
options for short-term or chronic insomnia include not only medications, but often sleep habit and behavioral modifications for optimal long-term results.
Evaluating sleep habits is important in the management of insomnia. Treatment of
underlying sleep disorders and in some instances, changing sleep habits may correct the problem without the need for medications. Good sleep habits
(also referred to as good sleep hygiene) should include:
- Regular sleep times
- A comfortable bed and quiet room at a comfortable, temperature
- A darkened room
- Regular exercise,
but not close to bedtime or late in the evening - A bedroom that is not used for work, watching television, or other activities not related to sleep
other than sex - Avoid of stimulants (for example, caffeine, or tobacco),
alcohol, and large meals close to bedtime (avoid 2-4 hours before bedtime
if possible) - Many people watch television before falling asleep. TV can be a very
stimulating medium and needs to be closely evaluated if it adds to a person’s
insomnia. - Relaxation techniques such as breathing exercises or yoga
- No naps during the day
- Try drinking warm milk before bed. It is high in the amino acid tryptophan,
which helps induce sleep.
QUESTION
What is insomnia?
See Answer
Can melatonin treat insomnia?
Melatonin (for example, Melatonex) is the only hormone available OTC for insomnia. Melatonin is a hormone produced by the pineal gland that helps regulate the body's clock or sleep-wake cycle. The secretion of melatonin is increased by darkness and decreased by light. The exact mechanism of how melatonin induces sleep has not been determined. Melatonin also decreases mental alertness and body temperature.
Melatonin is sold as a dietary supplement and is, therefore, not regulated by the FDA. It is commonly used for jet lag, insomnia, and sleep disturbances related to working night shifts. Some limited evidence suggests melatonin may be useful for treating sleep disturbances.
In 2005, MIT analyzed 17 peer-reviewed studies using melatonin. The analysis showed that melatonin was effective in helping people fall asleep at doses of 0.3 milligrams (mg). In some preparations the dosage of melatonin is significantly higher and these larger doses have shown to be less effective after only a few days of use. If possible, patients may want to stay with the same formulation or brand if it is effective for them.
If a person would like to try melatonin tablets, consult a doctor first.
Dosing: There is no established dose or time of administration. Individuals should follow the product labeling for dosing and administration.
Pregnancy and lactation: The use of melatonin during pregnancy or lactation has not been studied adequately. Based on past experience with other agents and the possibility of unknown risks to the fetus, melatonin should be avoided during pregnancy while breastfeeding. Consult your doctor before you use melatonin if you are pregnant or breastfeeding.
Children: The use of melatonin in children may be effective, particularly in children with disturbed sleep due to autism spectrum disorders. However, it should not be used as a first-choice treatment in children. Consult your pediatrician before giving your child melatonin for sleep.
Drug interactions: Although melatonin is sold as a dietary supplement, it should be thought of as a drug. It has side effects and may have drug interactions that have not been identified. The level of melatonin that the body produces is increased by certain drugs, such as selective serotonin reuptake inhibitor antidepressants or SRRIs (for example, fluoxetine [Prozac], sertraline [Zoloft], paroxetine [Paxil]) and monoamine oxidase inhibitors (for example, tranylcypromine [Parnate], phenelzine [Nardil]). The interaction between these antidepressants and melatonin used as a sleeping aid has not been assessed.
Side effects: The most common adverse effect of melatonin is drowsiness. Therefore, tasks that require alertness (for example, driving) should be avoided for four to five hours after taking melatonin. Melatonin also may also cause itching, abnormal heartbeats, and headaches. Melatonin appears to be safe when used short-term (less than three months). Long-term side effects of melatonin are unkown.
Melatonin is either derived from animal sources or synthesized in a laboratory. Melatonin obtained from animal sources has a higher likelihood of contamination, which can cause allergic reactions and viral transmission, than synthetic melatonin.
Melatonin may stimulate the immune system. People with severe allergies or other disorders that may be caused by an overactive immune system (for example, systemic lupus erythematosus, rheumatoid arthritis) should avoid using melatonin.
Other herbal products: Natural herbal supplements such as valerian, chamomile, kava kava, and others have been touted as remedies for insomnia; however, the safety or effectiveness of these products has not been documented. Consult your doctor before taking any herbal supplements to treat insomnia.
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What over-the-counter (OTC) medicines are there for
insomnia?
Self-treatment of insomnia with over-the-counter (OTC) drugs is advisable only for transient or short-term insomnia. OTC sleep aids should only be used for a short period of time in conjunction with changes in sleeping habits. Chronic use of these drugs may result in dependence on them. This creates a situation in which sleep is not possible unless the drug is used. Chronic insomnia should be evaluated by a physician.
Antihistamines
Diphenhydramine (for example, Sominex, Nytol) and doxylamine
(for example, Unisom) are antihistamines currently marketed as OTC sleep aids. Diphenhydramine is
the only agent considered to be safe and effective
by the Food and Drug Administration. Other uses for diphenhydramine include
allergies, motion sickness, and cough suppression.
Scientists believe that diphenhydramine and doxylamine
cause sedation by blocking the action of histamine in the
brain, but the exact mechanism of action is not known.
If insomnia is associated with pain, there are numerous
products containing a combination of an antihistamine and
pain reliever. These combination products should not be
used if pain is not present because the added pain reliever
is not necessary.
Pregnancy and lactation: The effects of diphenhydramine
and doxylamine on the fetus have not been evaluated
adequately. Diphenhydramine is classified as a pregnancy "category B"
drug, and is routinely safely used during pregnancy. Although the likelihood of an adverse effect on
the fetus is low, sleeping agents probably should be avoided
during pregnancy. Both agents may decrease lactation
(production of milk). Additionally, these drugs are
secreted into the breast milk, which could affect the
newborn. Nursing mothers should avoid both
drugs. Consult a physician if you are pregnant and have insomnia.
Children: Children less than 12 years of age should not use
doxylamine because its use in this in age group has not
been assessed.
Elderly: Sedative effects of these drugs may interact with other
potentially sedating medications. Consult a doctor before
using these drugs.
Drug interactions: Diphenhydramine and doxylamine add
to the sedative effects of alcohol and other medications
that cause drowsiness.
Side effects: Drowsiness is the most frequent side
effect of both diphenhydramine and doxylamine. These agents should not be used in situations where mental alertness is required
(for example, driving). Diphenhydramine and doxylamine also cause constipation,
dry
mouth, and difficulty urinating. Both drugs may worsen the
symptoms of glaucoma, asthma, heart problems, and
prostate
gland enlargement. People with these conditions should not
use OTC sleep aids without consulting a physician.
Both drugs may paradoxically cause excitation, resulting
in nervousness and insomnia. This occurs most often in
children and the elderly.
What prescription medicines are there for insomnia?
There are numerous prescription medications options a doctor may prescribe if a person is suffering from short-term or chronic insomnia. Most are not recommended for long-term use.
Medication to treat insomnia includes several classes of drugs;
- Short-acting sedative-hypnotics (non-benzodiazepines) – these medications slow activity in the brain to allow sleep.
- zolpidem (Ambien, ZolpiMist)
- Intermezzo was approved by the FDA in 2011. It is a form of zolpidem, taken sublingually (dissolved under the tongue) and in smaller doses than Ambien.
- zaleplon (Sonata)
- eszopiclone (Lunesta)
- zolpidem (Ambien, ZolpiMist)
In 2007, the FDA issued a warning in regard to sedative-hypnotic drugs and their risks, which "…include severe allergic reactions and complex sleep-related behaviors, which may include sleep driving. Sleep driving is defined as driving while not fully awake after ingestion of a sedative-hypnotic product, with no memory of the event." The recommended dosing has recently changed ans is different based on gender and other factors. You should ask your doctor and pharmacist about appropriate levels and warnings.
- Orexin receptor antagonists – suvorexant (Belsomra) – this is a newer classification of insomnia medication working on orexin receptors in the lateral hypothalamus in the brain. The drug acts by decreasing activity in the wake centers of the brain and helping patients transition to sleep. This is in contrast to traditional insomnia medications which attempt to increase activity in the sleep centers of the brain. The medication is generally thought to be safe an well tolerated but some side weffects may occur.
- Melatonin receptor agonists – used to help patients who have difficulty falling asleep and it works similarly to melatonin
- ramelteon (Rozerem): Ramelteon is a medication taken by mouth 30 minutes prior to bedtime. Ramelteon should not be taken if the patient will not be able to sleep for at least 7-8 hours. Insomnia usually improves in 7-10 days.
- One of the advantages of ramelteon over other prescription sleep medications is the lack of dependence on the medication.
- Benzodiazepines (tranquilizers) – this class of medication is used to slow down the central nervous system, causing drowsiness. These medications have a high risk of dependence with chronic usage.
- Tricyclic antidepressants: Tricyclic antidepressants are medications work by increasing the amounts of certain natural substances in the brain that are needed for mental balance.
If your doctor recommends prescription sleep medications:
- Follow all prescribing instructions given by your physician.
- Tell your doctor any other medications or supplements you take as many can have adverse interactions with sleep medications.
- Tell your doctor about any pre-existing medical conditions.
- Note any possible negative side effects (changes in your body, and even your emotions)
- Do not use the medications nightly unless instructed to do so by a doctor – this can lead to dependence.
- Avoid drinking alcohol or taking other non-prescription drugs while using sleep medication.
- Never drive a car or operate machinery after taking a sleeping pill.
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What stimulant products are available OTC?
People with insomnia often suffer from fatigue as a
result of sleep deprivation. Stimulant products are
frequently used in an attempt to offset fatigue and other
unpleasant side effects that can accompany a lack of sleep.
(These products are also used by people who need to stay
awake for longer periods of time than is normal for them,
such as for school examinations or long distance driving.)
However, the use of stimulant products can also cause
insomnia, leading to a counterproductive effort to deal
with sleep deprivation.
Caffeine
Caffeine (for example,
NoDoz, Caffedrine) is the sole active
ingredient in most non-prescription stimulants. It is the
only drug approved by the FDA for this purpose. Caffeine is
used for improving alertness and for staying awake.
Caffeine is a powerful stimulant, but tolerance (the need
to use increasing amounts) can be developed. Caffeine also
is present in medications for menstrual cramps, headaches,
and colds. Additionally, caffeine is found in coffee, tea,
soft drinks, and chocolate.
Caffeine increases alertness by stimulating the nerves
in the brain and spinal cord. It decreases muscle fatigue
by stimulating muscle contraction. Caffeine also increases
the heart rate and the force of contraction of the heart.
The effect of caffeine varies among individuals and some
people are only affected minimally.
Pregnancy and lactation: Studies have shown that
moderate caffeine intake does not cause low birth weights,
miscarriages, or premature births. However, there are
reports of birth problems in women who consume more than
300 milligrams per day of caffeine. Daily
caffeine intake should probably be limited to less than 300
milligrams during pregnancy.
Caffeine passes into breast milk. The concentration
of caffeine in breast milk is approximately one-percent of the
amount in the mother’s blood. A lack of sleep and
irritation may occur in breastfed infants whose mothers
consume more than 600 milligrams of caffeine per day. No
adverse effects have been noted in breastfed infants whose
mothers consume between 200-336 milligrams per day of
caffeine. A mother can limit the amount of caffeine her
infant receives by limiting the amount of her caffeine
intake and ingesting the caffeine after nursing.
Children: Caffeine is not recommended for children less
than 12 years of age.
Elderly: Older persons may be more sensitive to the effects of caffeine,
and it may incrase the excretion of calcium from the body. In limited amounts,
it is generally considered safe.
Drug interactions:
Cimetidine
(Tagamet), norfloxacin
Noroxin, ciprofloxacin (Cipro), and the estrogens in
oral
contraceptives block the break-down and elimination of
caffeine from the body. Use of caffeine with these drugs
could lead to increased levels of caffeine in the body and,
therefore, a higher likelihood of side effects.
Caffeine decreases the absorption of iron tablets. Iron
should be administered one hour before or two hours after the
consumption of caffeine.
Caffeine decreases the effects of sedatives, and
sedatives decrease the restlessness, alertness, and arousal
caused by caffeine.
Adverse effects: The most common adverse effects of
caffeine are insomnia, nervousness, excitement,
headaches,
vomiting, diarrhea, and stomach pain. Caffeine also causes
abnormal heartbeats and increases heart rate.
Dependence can occur from the regular use of caffeine.
If caffeine intake is stopped suddenly, a withdrawal
reaction that consists of fatigue, headaches, anxiety,
vomiting, and restlessness may occur. Symptoms of
withdrawal start 12-24 hours after the last consumption of
caffeine and may last for a week.